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This Week in The Lancet

  • Volume 377 1719 (2011)
  • May 21, 2011

Africa

An elective report in Zanzibar – In collaboration with the LINK-Z Project

Wednesday, November 17th, 2010

My main enjoyments of medicine so far have been surgery, so I was keen to go somewhere where I could experience surgery in a different setting and see other types of medicine. Going to a third world country was always on my list because I have never experienced the types of medicines utilized there. Zanzibar, being a small island with one main hospital, Mnazi Mmoja, therefore sounded ideal. Finding out the hospital was right next o the beach and being in the Indian Ocean was also a small incentive!


The population of Zanzibar is 800 000 and growing1. Zanzibar’s health system is funded primarily be government sources, although there are external sources of funding. Private hospitals get their funding elsewhere. The life expectancy here is an astonishing 48 years2.


My first day at the hospital began with a stark introduction into the healthcare system in Tanzania, as well as an orientation around the wards. On first impression of the wards, I could not believe that it was medicine it’s most primitive state being used. The more I saw, the more fascinated I became with how much clinical medicine is relied upon here, and how fortunate we are in the UK to have the NHS system and not have to pay for simple tests such as blood tests or urine dips. These each cost around 1500 shillings, which equates to approximately 80 pence. For some families these tests are paid for but only in life and death situations – literally.


The theatre

The most common cases I saw on all wards are listed below;

Malaria
This is the leading cause of outpatient and inpatient health service attendance, and the leading cause of death in both children and adults1. On my first day it became apparent how prevalent Malaria is, based on how often a patient was diagnosed with malaria.

Anaemia

Most cases were due to malnutrition or secondary to ‘malaria’. The phrase ‘this patient has anaemia secondary to Malaria’ bacame a standard to expect at the end of every clinical assessment, regardless as to whether or not the patient had a positive Malaria screen.

HIV

After speaking to a government official on the island regarding the effect that HIV was having on the island of Zanzibar, he explained to me that the government here is investing a lot of time and money into researching how HIV awareness can be promoted and how HIV itself can be prevented/treated. Here in Zanzibar the HIV treatment is free as part of a government initiative to increase the amount of people receiving treatment and being aware that testing is available for free.

I began in the surgical department, were my first impressions of the surgical theatres were grim. At a glance I might have mistaken the area as a scene from a torture chamber. It is the most primitive medical setting I have seen, yet I was surprised at how much successful surgery occurred at Mnazi Mmoja. There were no sterile fields, and scrubs for seniors were ironed in the theatre waiting area.


Orthopaedics

Having found a consultant who seemed keen to teach, I found myself on the orthopaedic ward much more than I expected and thoroughly enjoyed it. Orthopaedics seems to be one of the medical professions in which there is a minimum standard; even in the 30°C heat, the orthopaedic surgeons still managed to be the sharpest dressed people in the hospital with the three piece suit. As for the profession itself, orthopaedics were one of the most advanced types of medicine I saw for a ‘third world country’. Granted the theatres were basic and the equipment did not consist of the flashiest gadgets the surgeons could get their hands on, but the level of skill and knowledge was on par with western medicine. Fractures are set or surgical realigned if needed, and open fractures are cleaned in a sterile environment, but there are no positive pressure areas in theatre.

RTA patient on Diclofenic only

In my first week on the surgical ward, a teenager was admitted and rushed straight to theatre as the only survivor of a car involved in an RTA collision with police car. The orthopaedic surgeon had the job of repairing 7 broken bones in both legs and setting his left arm in plaster. The surgery lasted only three hours and the patient was put into multiple tractions whilst he remained in ITU.

It shocked me to see this young boy in traction after such a horrific accident, and his only mode of pain relief was with an anti-inflammatory (Diclofenac).


Paediatrics

My next two weeks were then spent on the paediatric wards; I found myself sadly becoming less affected to the tragedies of children dying here on a daily basis. My first experience of this was whilst waiting for a ward round to begin in the nurses’ office, and realizing there was a baby lying under a  kanga (basically a sarong) having died the previous night.


The bonus to paediatrics was the heart clinic. In the UK infants with serious heart defects are treated much younger than they are in Zanzibar ,and as a result we have less clinical exposure to these signs and often don’t gain the experience of listening to such a varied degree of heart murmurs. I feel that this was a large advantage of my elective and now feel slightly more confident in listening to abnormal heart sounds. I also saw several cases of serious hydrocephalous. These patients were not treated when neonates and no shunts were inserted. Plastic surgery is possible, providing the family were able to afford sending their loved one overseas for treatment. The worst case of this was a two year old boy who could not physically support the weight of this own head, it was larger than two rugby balls put side by side.


As part of my elective I took part in a maternity audit project which I arranged to do in collaboration with the LINK-Z project prior to going to Zanzibar. Anyone going on elective should consider this, as it is a great thing to have on your C.V, and is easy to complete over a few afternoons on elective.


After speaking to one of the midwives, she explained that as part of the LINK-Z project, obstetric consultants from the UK come to work at Mnazi Mmoja for months at a time. She said this process has given the ward more structure and guidance on how to run a maternity ward. It appears to me that the LINK-Z project has been detrimental to the improvement of this particular ward.


Many students, like me, begin our elective expecting to make a difference in a third world country and to be praised for our every effort. In actual fact, we probably hinder the system by slowing down the ward rounds and clinics by having explanations as to why things are done differently, not to mention the translation issue.

Mnazi Mmoja is a friendly and vibrant place and I made some great friends there and now have a full appreciation for clinical skills/ clinical diagnoses.


For more information on Mnazi Mmoja and carrying out your elective there, email Dr Omar at the hospital on anwasul@yahoo.com. The hospital fees are $75 per week. I would advise taking a few pairs of scrubs to wear whilst in hospital, as it gets very hot. Other students were told to bring white coats before hand, but they get very hot and none of the staff there mind what you wear. Accommodation is sorted through the hospital and costs around $15 per person per night – it is basic but clean. They often come with a living area, balcony and kitchen, however it is dirt cheap to eat out; 75p can get you a decent meal where the locals eat. Be warned most accommodation the hospital set you up with does not have air-conditioning and a mosquito net is a must have!


In conclusion I cannot emphasise how progressive this elective was in increasing my clinical skills, as well as my knowledge for tropical diseases. I found that due to the lack of resources such as simple blood tests (which we take for granted in the NHS), I had to rely on my clinical knowledge a great deal. My elective most certainly made me much more appreciative of the NHS system ,well as the extensive training our doctors must go through.

My friends and I on the mountain

For anyone thinking about an elective in Zanzibar, I can’t think of a better place to experience a different kind of medicine with the prospect of seeing all kinds of weird and wonderful. As part of our time out from medicine, my friends joined me on my last week to enjoy the beaches after climbing Mount Kilimanjaro. Between the four of us we raised £4000 for three different charities, (although I must add that climbing the last seven hours ascent of Kilimanjaro was like ‘climbing out of hell’, so perhaps I’d advise medical students to skip that part of the trip or take plenty of chocolate to keep your spirits up!) The disruption of the volcanic ash clouds that played havoc with incoming European flights was an added bonus… I can’t think of a better place to be stranded than the Indian Ocean.

Rebecca Rollet

Warwick University, UK.

References

  1. United Republic of Tanzania PDF Government document. Available at: http://rbm.who.int/wmr2005/profiles/tanzania.pdf
  2. LINK-Z project Presentation about Zanzibar at a World Health Organisation meeting. Available at: www.who.int/social_determinants
  3. Zanzibar government Ministry of health and social welfare 2009. Tanzanian government website. Available at: http://zanzibar.go.tz
  4. World health organization (WHO) website. Available at: http://www.who.int/countries/tza/en/

Shocking revelations during an elective in under-resourced Tanzania

Tuesday, October 26th, 2010

As part of my final year curriculum, I undertook my elective rotation at Mount Meru Regional Hospital in Arusha, Tanzania. I decided to do my placement in a developing country because I had never worked in such a setting before and believed it would be a fantastic experience to have. I did not know where I wanted to go at first, but after trawling through multiple Google searches, I found Work the World – a UK organisation that arrange elective placements for healthcare students in Africa, Asia and South America. Email discussions with the staff found me selecting Tanzania as my destination, and from then on there was not much left for me to do as they helped me to sort out all of the necessary logistics.

During the six weeks that I was there, I worked in a variety of areas; spending time in Paediatrics, General Medicine, Obstetrics & Gynaecology and Surgery. As much as I tried to, nothing could have prepared me for the reality of an under-resourced hospital. The other main challenge that I faced was the language barrier; even though we were given weekly Swahili lessons, there was only so much that I could learn in that short amount of time.

Paediatrics

I attended ward rounds daily, which involved taking histories with my limited grasp of the Swahili language and examining the children. The common conditions were Malaria, Pneumonia and Gastroenteritis. Through discussions with the doctors, I learnt more about these conditions and their presentation. At the same time, my opinions on diagnosis and management were always taken into account, making me feel like part of the team.

The Paediatrics ward

The Paediatrics ward

In addition, I had the opportunity to attend the HIV clinics, which children with the condition visit monthly. Their CD4 counts are monitored and they get a prescription for monthly anti-retrovirals. All HIV-related consultations, investigations and treatments are free. Through this clinic I learnt a lot about HIV and its related illnesses, and it was comforting to see that there are active measures in place to cope with this problem. I was also told by the doctors that there are a lot of media campaigns with regards to preventing the spread of HIV, be it in newspapers or television. However, not everyone has access to these, so there are still people who are ignorant about the condition.

General Medicine

Like in Paediatrics, I attended ward rounds in General Medicine daily as well, and got to see a wide variety of conditions. Infectious diseases such as Tuberculosis, Leprosy, Malaria and Schistosomiasis were common. There were also many patients with HIV-related illnesses, such as Kaposi’s Sarcoma and Cryptococcal meningitis. One of the cases that I will never forget was a patient with Stevens-Johnson Syndrome secondary to sulphur allergy. I had never seen that before, and it was interesting to see the evolution and resolution of the condition as she got better with treatment.

After seeing a condition that was new to me, I went back, read about it and discussed with the doctor the next day. This has indeed put perspective and reality to some of the conditions that I have always read about in books but have never seen in real life.

One thing of note is that there are not as many investigations available there compared to back in Australia. As such, diagnoses are often made based on just the history and examination. This has taught me to be more thorough in my clinical assessment, and not to rely too much on investigations. It has also made me more appreciative of the resources we have back home.

The most memorable experience on General Medicine was doing a lumbar puncture. I had seen one being done when I was in third year, but have never done any. The conditions were not exactly the most sterile – I did not have a sink to wash my hands so I had to just clean them with the chlorhexidine solution I had; the patient’s skin was cleaned with alcohol swabs; and there were flies in the ward which could potentially land on the areas that I had cleaned. I learnt to just make do with whatever was available, and tried my best to ensure that the procedure was as sterile as possible.

Despite my initial fears that I would not do it right, I succeeded in collecting a sample thanks to the supervision and support of one of the doctors, who guided me step-by-step during the whole procedure. I am glad that I have had this experience, and hope that it will help me perform my next lumbar puncture more competently.

Obstetrics & Gynaecology

There was a lot of hands-on experience in O&G. I spent most of my time on the labour ward, where it can get very busy. There were times when I had to do deliveries on my own because there was simply no one else around to help me. It was daunting at first, but as I slowly got used to it I became better at it. Hearing the mothers-to-be scream out in pain because they do not get any pain relief was quite horrifying, and even more horrifying was seeing the nurses slap them in order to keep them quiet.

I also got to insert IV cannulas, as well as do venipunctures on patients who were going to theatre. In addition, I assisted the doctors and nurses in admitting patients, so I got to practice doing antenatal examinations and vaginal examinations. Antenatal care is not ideal, as most women only visit the clinic once or twice during their pregnancy, resulting in a lack of monitoring; I saw 2 cases of Foetal Death In Utero (FDIU) while I was there.

There were times when I had to resuscitate the newborns, with minimal equipment such as a bag and mask, and a manual suction pump. Unfortunately, during my time there, I saw babies that did not survive. It was sad, and it made me reflect on how we could have done more if we had better facilities.

Newborn resuscitation

Surgery

My week in surgery was spent doing surgical ward rounds, as well as observing in theatre. Conditions in theatre were not exactly sterile, as there were broken window panels which allowed flies into the theatre, some of which landed in the sterile field.

The most impressionable procedure was the Open Reduction Internal Fixation (ORIF) of a fractured clavicle. Dr Lee, a volunteer orthopaedic surgeon from South Korea, was the only orthopaedic expert around as all the other surgeons in this hospital were only trained in general surgery. This meant that his assistant could not help him much, resulting in a prolonged amount of time taken to perform the procedure. Moreover, because orthopaedic equipment is scarce, the metal wires had to be manually drilled into the bones. This took a long time as it was difficult to get the wires in the right direction, and they had to insert them multiple times before succeeding.

The metal wires were long, and they did not have a wire cutter. Dr Lee told us he was going to buy it from the market that afternoon. This baffled me – if they knew that they did not have all the necessary equipment, why not postpone the surgery? The patient was not in great danger at that point. At the end of the surgery, they left the metal wires sticking out of the patient like this:

ORIF of a fractured clavicle

ORIF of a fractured clavicle

On the same subject of lack of orthopaedic equipment, they do not have pins to fix fractured femurs. As a result, the wards are filled with old ladies with osteoporosis and fractured femurs from falls, with traction applied using a bag of stones. That seemed to me as being innovative, making use of whatever they had.

Management of fractured femurs

Management of fractured femurs

In conclusion, it was a valuable experience observing the huge contrast between healthcare in Tanzania and Melbourne. Working in the hospital and discussions with staff members enabled me to understand more about the limitations they have, be it expertise or material resources. I also learnt about the conditions that are common there, as well as contributing to the care and management of patients on the wards. If I had to choose again, I would definitely still choose to do my elective in Tanzania!

Jasmine Koh
Monash University, Australia

A Split Medical Elective: Tanzania vs England

Tuesday, October 26th, 2010

When planning my elective I was presented with a choice; travel to Tanzania for a cultural experience, or stay in England and have the chance to improve my clinical skills and undertake more academic work. The decision wasn’t difficult – I should do both! So I spent the first part of my elective at a hospital in Tanzania, and the second half in a hospice near Manchester. Both experiences have been fantastic and have helped me prepare for my final year and future career.

In the summer preceding my intercalated year in Biomedical Ethics, I had volunteered at a small orphanage in Bagamoyo, Tanzania, which provides care whilst foster or adoptive care is sought. Sadly, there is a growing number of orphans in the region, largely due to the HIV pandemic. Although there have been great advances in HIV care resulting in reduced mother to child transmission rates, mothers may not always continue long-term antiretroviral (ARV) therapy (1). This means that the ‘middle generation’ is dying, and many children are left without their parents (1). Whilst volunteering I had the opportunity to visit the HIV clinic, accompanying a child from the outreach programme whose family were too sick to take him. The clinic seemed well organised, and I was impressed by the care received.

The busy HIV clinic

The busy HIV clinic

Working with the home was an amazing opportunity, and despite the devastation so many people face every day, Bagamoyo (meaning “lay down my heart”) is one of the friendliest, uplifting places I have ever been to (2) – I really did lay down my heart! I fell in love with the town, culture and people. I knew I had to go back for my elective and get more involved with the hospital.

This year I arranged to spend part of my elective in Tanzania so I could revisit this wonderful town. I hoped I would be able to assist at the hospital, learn more about how healthcare is provided in Tanzania, the difficulties faced. I also wanrws ro to forge relationships with the doctors, as I wish to return when qualified.

Returning to this town was amazing. It is a truly magical place, despite difficult circumstances. There is plenty to see and do in the town, and everyone is keen to chat to you. It is the home of a large art college so many artists want to show you their paintings, carvings and sculptures, hoping for a sale. Some of the local children even invited us to see them perform traditional dancing in a group they have set up, hoping to raise money so they can pay school fees and continue their education. Local food was fun to try and cheap. A chip omelette cost about £1, a bottle of coke was 25p and a bottle of beer 50p!

The entrance to the hospital in Bagamoyo

The entrance to the hospital in Bagamoyo

The hospital in Bagamoyo, 80km from Dar-es-Salaam, is government-funded and serves the population of the town and surrounding district (approximately 80,000 inhabitants), alongside private clinics. The hospital has between 125 and 140 beds, and sees approximately 100 patients a day in the outpatient department. Whilst there, I was able to observe the doctors in outpatient clinics and on ward rounds. There are only five doctors with a medical degree working at the hospital. The other clinicians are medical officers with a diploma or advanced diploma in medicine. Sadly, the lack of resources puts a continuous strain on staff and the care they can offer. Frequently the doctor would explain standard treatment, and then explain that in their situation this could not be offered. I knew resources were limited, but I did not realise it was to such an extent.

Some patients have their prescriptions paid for, including children under five, pregnant woman and those patients taking ARV therapy. Medications for high blood pressure and diabetes that are prescribed in the outpatient clinic are also funded by the government. Yet when I sat in on this clinic, there were no diabetic medicines available and only limited anti-hypertensives, meaning patients were often prescribed different ones every time they were seen.

I observed how the culture and attitude of society can be a barrier to providing healthcare, and patient education programmes are a high priority. Treatment from traditional healers is often sought before advice from a doctor, and diseases are frequently advanced before a patient will come to the hospital. In the hypertension and diabetes clinic, we were told how many patients did not attend regularly, and so may only take medications for a few weeks of the year, despite suffering from the devastating complications of these chronic diseases.

HIV education has received more attention due its high prevalence (approximately 9%) and non-governmental organisation funding.(1) It was clear this had a positive impact. The patients who came to the HIV clinic were keen to be seen regularly, and brought their empty pot of ARV’s to show the doctor they were complying. The clinic was very busy, with two or three doctors trying to see 100 patients in one morning. Yet there are still many patients with HIV who do not attend the clinic, whether it is because they do not want to know their status, or simply cannot get to the hospital. Stigma around HIV means that many patients keep their status a secret, even from those close to them. HIV outreach clinics are held, but only when there is a car available to transport the team.

In preparation for the second part of my elective, and following my personal interests, I discussed palliative care with the senior doctor. He said that despite being taught palliative approaches at medical school (one week of teaching) and the number of patients with life-limiting illnesses, he felt it currently had a limited place in Bagamoyo. He was very aware of the importance of a holistic approach to healthcare, including psychosocial aspects, but said this was hard in practice due to limited time and the beliefs of patients. He explained that often patients do not believe their disease is terminal, as a traditional healer has offered a cure, and they would only listen if they saw a specialist at one of the bigger, well-equipped hospitals.

A general medical and surgical ward

A general medical and surgical ward

My overriding impression from my time at the hospital was how frustrating it was for the doctors not to be able to offer the treatments they knew could help. I had gone expecting this, and naively thinking that more resources would quickly change the situation. However I learned that the culture and attitudes of patients mean that for changes to be made, education would have to play a key role.

When I returned to England for part two of my elective experience, I was quickly thrown into a very different situation. The pace of work was much quicker than twat I had got used to with the ‘slowly slowly’ way of living in Bagamoyo.

Interestingly, this placement quickly reinforced the importance of international links, strengthening my desire to return to the hospital. I was able to see the success of a project between the hospice, a doctor in Portugal and a psychologist in Brazil, involving the development of a ‘Multiprofessional Toolkit’. This is a patient held healthcare record that enables patients to share their preferences for care as they reach the end of their lives.

Willow Wood Hospice in Ashton-under-Lyne, approximately 7 miles outside of Manchester offers palliative care to patients with life-limiting illness through a 12 bedded inpatient unit, an outpatient clinic and day hospice. Patients may be seen for terminal care, symptom management and occasionally respite care. The hospice believes in a holistic approach to care, and therefore offers complimentary therapies and chaplaincy alongside medical care. I hoped to improve my knowledge of palliative care, practice my clinical skills and undertake an audit project, looking towards publication.

Whilst I have been at the hospice I have been able to observe and participate in both the outpatient and inpatient department, getting plenty of hands on experience. I have had the opportunity to lead consultations, help admit patients and even write the letters to GPs.

Alongside the clinical work I have also been able to undertake an audit project. The first part of this was an internal documentation audit, looking at whether the cognitive assessment tool included in the inpatient admission proforma was always completed. The second was a national survey where I contacted 200 hospices to ask whether they used a cognitive assessment tool. This has been an interesting project, where I have been able to consider the ethics and usefulness of using assessment tools when patients are at the end of their lives, and enabled me to learn the important audit cycle. I have also been able to improve my team-working skills by collaborating with two doctors to submit two rapid responses to journal articles regarding palliative care. This has been not only a rewarding experience, but also really useful. I have not previously had the chance to co-author a piece of work so it was great to be able to develop this skill.

Both of these placements involved the care of patients where there was only limited treatment available, either because of funding or because of advanced disease. It was interesting to observe the different approaches in these situations. At the UK hospice a palliative approach was taken, and much was still done to improve a patient’s quality of life or comfort. This was achieved by a multidisciplinary team approach.

However at the Tanzanian hospital, when a patient was dying little could be done to help alleviate their suffering. Diclofenac was one of the strongest pain killers prescribed. Besides the doctor on the ward round, the staff who manned the ward for most of the day were mainly young trainee healthcare assistants. When we arrived on the ward one morning, a patient was struggling to breathe due to pulmonary oedema, yet no one had known that sitting the patient up would help. As soon as the doctor did this the patient was much more comfortable. Patients discharged home with a life limiting illness would not receive any palliative care, and may not realise their prognosis. Perhaps in Tanzania it is not funding that is needed but also palliative care education to demonstrate how much may be achieved when there is little to alleviate suffering at the end of life.

I found it extremely valuable undertaking two separate placements for my elective and would recommend it to any medical student. It enabled me to experience health care in a developing country first hand, and learn about the struggles of providing care with limited resources. Language barriers in Tanzania meant that I could not practice history taking, and therefore a second placement in the UK meant that I could really develop my clinical skills in preparation for my final year. I was able to undertake academic work that I have not had the opportunity to do at university. I formed good links at the Tanzanian hospital and the UK hospice, and hope to return to both in the future.

I would recommend to any student planning an elective to consider what they hope to achieve. It is a great chance to target your learning to what you need – don’t waste it!

Acknowledgements

Many thanks to all the staff I worked with at the hospital and orphanage in Bagamoyo and at Willow Wood Hospice!

Charlotte Talbot
University of Leeds

References

1. Tanzania, United Republic of. [Web Page]: Unicef; 2006 [updated February 9, 2006]; Available from: http://www.unicef.org/infobycountry/tanzania_1254.html 2. Finke J. Rough guide to Tanzania. London: Rough Guides; 2002. Page 141.

Obstetrics in Tanzania

Tuesday, October 5th, 2010

I had always aspired to go to Africa for my electives to experience medicine in a developing country. I organised my elective with ‘Work the World’ and spent five weeks working in Obstetrics at Mount Meru District Hospital in Arusha, a large town nestling beneath Mount Kilimanjaro and Mount Meru in the north of Tanzania.

- 097

The hospital had an eleven bed labour ward, a post-natal ward, sluice and a theatre just for obstetrics and gynaecology. The labour ward was busy but very poorly staffed and equipped. The drug cupboard was just a small shelf with few medications on it and sharps such as broken vial glasses laid all across the floor. Even though cardboard boxes were provided for sharp objects, they were generally full. There were often two midwives and sometimes just one Tanzanian junior doctor looked after a full labour ward. There was no privacy in the ward and infection control was supposedly very limited. Though they had their own sterilising machine only a few people knew how to operate it, hence the availability of the sterile equipment was limited to occasional days. When there was no sterile equipment, two gloves and a sterile surgical blade were used to cut the umbilical cord.

On arrival to the hospital, women had a vaginal examination and were only admitted to the labour ward when they were at least 4 cm dilated; some others, arrived at dilutions as high as 9-10 cm. On one occasion, I delivered a baby just as the woman walked into the labour ward. Women were expected to bring with them kangas (sheets of material) to cover the bed and to wrap the baby in, sterile gloves, oxytocin, cotton wool, needle, and syringe. No analgesia was given during labour. It was often hard to listen to the shouts and screams of women in pain. I used to rub a lot of backs, held many hands and practised my poor Swahili. I was pleasantly surprised to find that every woman had a partogram.

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I personally delivered twenty one babies and assisted in many more during my elective. And despite the lack of facilities, it was all a wonderful experience. Except on occasions when I had to deliver stillborn babies. At times the duty seemed to be a bit tough as well. Once I was alone in the ward with an intern, when I had to artificially rupture the membranes. On examination I found out that the cord had prolapsed. I instantly asked the intern to fetch senior help. Unfortunately, the help did not arrive until 30 minutes later and the baby died.

This was not the only complication I witnessed or had to deal with. Oytocinon infusions were used to progress labour and were useful in many primigravidas but there was not enough staff to effectively monitor the patients, which sometimes resulted in uterine rupture. The babies were sometimes delivered before the restitution occurred and with the cord still wrapped around their neck. Besides, many times the midwives did not wait until the uterus had contracted before pulling out the placenta, resulting in retained placentas and post-partum haemorrhages. However, I was pleased to see that every woman was given an intramuscular injection of ten units of oxytocin to reduce the rates of post-partum haemorrhage. Shockingly, the midwives did not like doing episiotomies and instead preferred to put their full weight on the abdomen and forced the foetus out. Caesarean sections were performed in a sterile manner under spinal anaesthesia.

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During my elective at this hospital, I resuscitated six newborns successfully, and tried to educate the Tanzanian midwives too on the procedures to resuscitate. One of my favourite moments was getting a baby to cry after almost ten minutes of it not breathing, turning blue and floppy. I bagged it, gave oxygen, suction and stimulation. It had probably aspirated meconium, and was taken to the premature unit.

Once born, every baby was shown to its mother, weighed and then put on a blanket underneath a heater. The placentas were delivered by controlled cord traction and sometimes examined to see if they were complete. Often midwives were left to suture very severe perineal tears. I sutured quite a few perineal tears using poor quality suture material and often without local anaesthetic as it had run out. Only saline was available to resuscitate women if they were hypotensive. After delivery, the mother was expected to get up immediately and walk to the post-natal ward where they were joined by their families. Sadly, women who had lost their babies were also taken to the post-natal ward. The postnatal ward was usually packed and women were supposed to stay there for 4 hours before they could go home, though many went home immediately after birth.

All these rough experiences were one of a kind and I am extremely happy that I chose Mount Meru Hospital for my elective. I learnt a lot from my elective in Tanzania and given a chance would love to return in future.

Felicity Avann

Trauma in South Africa: A cross-cultural elective experience

Tuesday, September 28th, 2010

by Samer Dabbo
Fourth year medical student, University of Toronto

Socio-economic background

South Africa is a middle-income country with a GDP per heard of US$3110.00 per annum, a population of 42 million, and a life expectancy of 46.5 years (males) and 48.3 years (females) [1]. Annual incomes vary by a factor of 17 between the highest and lowest socio-economic groups [1]. In general, 20% of the population is funded by private medical aids, usually subsidized by employers, while an estimated 80% are dependent on public healthcare facilities [1]. South Africa spends 7.1 % of GDP on health compared to 10.1% by Canada [1].

Disease Profile

Although the country transitioned to democracy in 1994, there is still a preponderance of developing world health concerns (e.g. infectious disease and trauma) in addition to the chronic and degenerative diseases common to the developed world [2]. Substance abuse, particularly alcohol, is a significant factor underlying many admissions [3]. Equally important, social factors such as widespread poverty, unemployment and income inequality create a climate of social exclusion that fuels crime and violence [4]. Compared to the United States, South Africa’s rate of violent death — 137 per 100 000 people — is 6 times higher [5]. Despite having legislation in place for protection of individual rights, gun control, and substance abuse, there is a small police to population ratio and an overburdened legal system.

Typical Day

Rotating through Trauma Unit 163 at Johannesburg General Hospital allowed me to work with a culturally diverse team to manage acutely ill patients with, at times, limited resources. Unlike i Canada, Surgeons and not Emergency Medicine doctors manage the unit. Teams are composed of two medical officers (completing internship year—similar to PGY1), one surgery registrar (at least a PGY2), four sisters (nurses), and a max of two elective medical students (clinical clerks). During my rotation, the unit had visiting students from around the world: Germany, Spain, England, New Zealand, and Libya. Shifts were either 7am-6pm or 6pm-7am. Handover occurred on all patients in the resuscitation bays (up to 16) at the start of each shift.

Although working in Unit 163 was unpredictable, prime time for trauma occurred on Friday, Saturday, and Sunday evenings. Violence (e.g. gun shots and stabbings), pedestrian vehicle accidents, and motor vehicle accidents were the most common causes for presentation. Not surprisingly then, there was no shortage of teaching opportunities. In dedicated rooms and once stabilized, I was given the autonomy to clean, prepare, and suture a patient’s wound. Once complete some patients would express their appreciation with kind words of encouragement, while others would simply sleep succumbing to the sedative synergy of excess alcohol and post-violence. Amid the controlled chaos of resuscitations, there were ample opportunities to perform ABGs, set-up peripheral lines, and review plain films. Despite differences in race, religion, and experience cases ran smoothly, under the watchful eye of a staff, as individuals adhered to pre-defined roles.

Samer Dabbo on the ward of Johannesburg General Hospital

With no official porter system in place, down time was often spent shuttling patients to and from the single CT scanner (16-slice) in the hospital. Superficially serving as a reprieve from the frantic pace of the unit, anxious moments lurked. For example, failing to check the supply of oxygen left in a portable cylinder before departing could result in precipitous drops in patient saturation during transfers. Luckily, wall-mounted oxygen sources were never too far off.

Eager to teach, medical officers and registars would often reward those who were keen to learn. For instance, I had a chance to be a first assistant in the OR for a laporatomy to repair a ruptured diaphragm when I decided to stay late one night. A few days earlier, I got to put in my first chest tube after I correctly spotted a hemothorax on the portable film. Uneasy during the blunt dissection, feeling the lung inflate against my finger energized me. Hearing the other team members announce that there was ‘bubbling and swinging’, indicating the correct position of the chest tube, signified their approval.

Unit 163 challenged me to practice medicine outside of my comfort zone while immersing myself in another culture and medical system. Despite witnessing bad outcomes and the brutality of humans, working with and learning from fascinating people from around the world allowed for a formative experience that I will not forget soon .

Safety

South Africa, and in particular Johannesburg, has often been touted as an unsafe place to live and work. Although I always felt secure in the hospital, regardless of the hour, traveling to and from work was at times anxiety-provoking. Unlike my commutes to the hospitals in the Greater Toronto Area, Canada getting lost on the highway and taking unfamiliar streets in Johannesburg left me feeling quite uneasy: “Was I entering a dodgy part of the city?” During orientation it was advised to avoid certain neighbourhoods near the hospital, such as Hillbrow and Yeoville due to the violence in these areas. Moreover, we were told that at night red lights could be treated like stop signs to avoid a car jacking. Despite these potential threats, the freedom afforded by having a car makes it difficult to dismiss renting one. If one did have reservations about driving though, hiring a taxi could be easily arranged.

Another potential threat to safety involved caring for patients. Similar to hospitals in Canada, needle stick injuries are not an uncommon occurrence. The risk of exposure to blood borne illnesses is significantly higher though. In fact, a recent audit of trauma units showed that there was a 37% prevalence of HIV among patients [3]. Thus, being aware of post-exposure prophylaxis protocols should be something that you discuss with staff before working your first shift. Participating in pre-departure training offered through your home university also goes a long way in helping to prepare you to face this and other potential scenarios.

World Cup

Working in South Africa during the World Cup allowed me to see first hand the effect that sport can have on a society. Given that this was the first time the tournament had been held on the African continent, there was a palpable buzz that could be felt (and heard – you’ve got to love those vuvuzelas) throughout the hospital. From murals encouraging Bafana Bafana adorning the walls to hanging flags waving from the ceiling, the hospital was transformed into a shrine for soccer. Spirited sisters proudly wearing the green and gold heralded the start of the games with songs and dance that could be heard throughout the hospital. It was clear that everyone had caught World Cup fever. For me, the most vivid images were those of doctors, patients, and staff congregating around TV’s to watch the opening match between South Africa and Mexico. I remember witnessing a Trauma patient request temporary relief from his wall-mounted oxygen therapy so that he could position his stretcher closer to the TV. Given the magnitude of the game, nobody denied his request. I get goose bumps when I think back to the intense outpouring of emotion that occurred after Tshabalala scored to put South Africa on top 1-0. Even though the game would end in a draw, you couldn’t help but feel the energy of a victory. While there is a lot of healing that needs to take place from the apartheid regime, hosting the World Cup not only showcased South Africa in a more favourable light, it also seemed to provide locals with a sense that things can move in a better direction.

Samer Dabbo was in South Africa during the World Cup for one of his electives

Conclusion

My trauma elective in South Africa was a great experience with reservations. I sincerely believe that by putting yourself out there and taking on adventures, good things happen or at the very least interesting things happen. It is crucial to be smart about taking risks; but doing so allows you to learn faster than people who don’t. Though difficult and overwhelming at times because of high patient volumes, limited resources, and increased responsibility, this elective allowed me to shift from “seeing” things – simply logging away memories – to doing things and learning things. Equipped with a broader range of experiences, new possibilities for a future career in medicine have emerged for me. In the end, if you are naturally curious, adaptable, and risk tolerant then I would strongly encourage you to seek out meaningful international electives.

1. A Guide to the Management of Trauma. University of Witwatersrand. J Goosen
2. Bowley DM, Parmar NK, Boffard KD. Burdens of disease in southern Africa. Lancet. 2004 May 8; 363(9420):1508.
3. Bowley DM, Dickson EJ, Tai N, Goosen J, Boffard KD. A theme issue by, for, and about Africa: South Africa is still blighted by trauma. BMJ. 2005 Oct 1; 331(7519):780.
4. Seedat M, Van Niekerk A, Jewkes R, Suffla S, Ratele K.Violence and injuries in South Africa: prioritising an agenda for prevention. Lancet. 2009 Sep 19; 374(9694):1011-22.
5. McClelland C. No shortage of teaching opportunities in Johannesburg trauma unit. CMAJ. 2002 Nov 12; 167(10):1160,

Oncology in Tanzania

Tuesday, August 17th, 2010

by Charlotte Brown
Fifth Year Medical Student, University Of Birmingham
DSC04747

Organising my medical elective took a lot of careful planning. Having visited Zambia in 2008, I was keen to go back to that part of the world and explore further. Originally, I had hoped to undertake my elective exclusively in the field of oncology. However, as I struggled to organise the elective project that I had planned, it became apparent that oncology is not recognised in the same way in Africa, as in the United Kingdom. With the help of Work the World, I was able to arrange a placement at the Bugando Medical Centre (BMC) in Mwanza, one of only four tertiary referral hospitals in Tanzania [1].

The BMC has a developing oncology department, which was founded just eight months ago with the arrival of a Tanzanian oncologist, who had just finished his specialist training in Italy. A placement at Bugando enabled me to see the reality of oncological care in Tanzania, whilst also providing an opportunity to experience other medical and surgical specialities in one of Tanzania’s largest hospitals, serving a population of over 10-million people [2]. I spent three weeks at the BMC, spending time in the oncology department whenever possible. I spent a further week on placement in a small village in the North of Tanzania, called Bukumbi, which was a stark contrast to my time in Bugando.

DSC05157The structure of the healthcare system in Tanzania is entirely different from that of the United Kingdom. Healthcare is provided by a variety of government, private not-for-profit organisations (e.g. mission hospitals), private for-profit organisations (including traditional healers) and company services [3]. The majority of facilities in the health sector are provided by the government, and Tanzania is one of the leading countries in sub-Saharan Africa with regard to healthcare provision [3]. However, the health sector is pitifully under-resourced, and basic requirements such as a regular supply of drugs at all government establishments remains a problem [1]. The structure of health services is as follows:

    – Village Health Service – each village assigns two village health workers, who are subsequently given a short training brief before providing services- Dispensary Services – each dispensary caters for between 6,000-10,000 people, and supervises all the village health posts- Health Centre Services – are expected to cater for 50, 000 people- District Hospitals – each district is supposed to have one of these. Many are provided by religious organisations who designate voluntary hospitals

    - Regional Hospitals – offer similar services to those offered at a district level, but may have specialists in various fields

    - Referral/Consultant Hospitals – there are currently only four of these in Tanzania. One of these is the Bugando Medical Centre

This pyramid structure of healthcare provision does not take into account the role of the traditional healer, an aspect of the healthcare in Tanzania that I found particularly memorable. Whilst placed at both the BMC and Bukumbi Hospital, I experienceed first-hand the ‘failures’ of the traditional healers. One particular case that a colleague of mine observed was that of a young boy who attended Bugando with his father. The child had just been diagnosed with Burkitt’s lymphoma, and had clearly evident ascitic swelling of his abdomen. Confusingly, the child also had a sizeable scar on his abdomen, apparently from a relatively recent burn. It later transpired that the boy had been taken to see a healer, who had attempted to burn the cancer out of him. I found it very hard to understand the reasoning behind this encounter, and it made all too clear to me the dangers associated with the strong culture of traditional medicine. While at Bukumbi, I was given the chance to visit the local traditional healer. This was an invaluable experience for me, and as I set aside my own personal views and pre-conceived ideas, I was able to gain some understanding into the local beliefs and traditions.

Whilst on placement, I was determined to discover what oncology in the developing World was really like. Having experienced cancer care at home, I couldn’t imagine how patients could cope without the support that we are so fortunate to be provided with in the UK.

Cancer is a leading killer worldwide, accounting for approximately one in every eight deaths [4]. According to the World Health Organisation (WHO), people in low-income countries tend to develop chronic diseases such as cancer ‘at younger ages, suffer longer – often with preventable complications – and die sooner than those in high-income countries’ [4]. The WHO states that ‘a well-conceived, well-managed national cancer control programme lowers cancer incidence and improves the life of cancer patients, no matter what resource constraints a country faces’ [5]. My time in Tanzania has highlighted to me that even working within a budget as small as that of the BMC there are improvements to be made in order to tackle the problem head-on. An example is the provision of training facilities within Tanzania itself. There are no oncological training facilities within Tanzania [6], and any doctors wishing to practice in the field of oncology must study abroad. This often poses its own difficulties, and staff may return to Tanzania to find that what they have spent time learning abroad is in many ways irrelevant to life in Tanzania [6].

Twalib Ngoma is one name with an extremely strong link to cancer care in Tanzania [6]. As a medical student with a keen interest in oncology, Ngoma pioneered the establishment of the Ocean Road Cancer Institute (ORCI) in Dar-es-Salaam in 1996 [6]. Ngoma found that ‘the priority rating for cancer was low’ [6], yet has managed to develop provision for cancer sufferers in Tanzania, with plans to open four more cancer centres in the next decade [6].

All_in_1Presently, there are only a small handful of population-based cancer registries in Africa, covering little over 11% of the total population [7]anzania itself lacks a population-based cancer registry [8] and therefore it is very difficult to estimate the total burden of the disease in the country as a whole. It is currently estimated that the incidence of cancer in Tanzania is 70 per 100,000 of the population [8] though I believe this to be an underestimate.

Evidently, healthcare in Tanzania is run to a low budget, which goes a long way to account for much of the variation, for example, lack of histopathology departments and availability of chemotherapy agents, particularly second-line drugs. However, many of the differences I found are due to the different organisation of UK and Tanzanian cancer provision. For example, the multidisciplinary team (MDT) forms the foundation of healthcare provision in the U.K., perhaps in the oncology setting more than most. In Tanzania it seems that although various health professionals work alongside each other, they don’t work to support each other. I attended a screening clinic at Bugando, and after being overjoyed to find a screening clinic up and running, I was saddened to see the lack of people attending. I spoke to the oncologist at length about why the clinic was so quiet, and he informed me that in his opinion education has the biggest role to play in the process of making people more health aware. This is supported by a recent paper published in the East African Journal of Public Health, which found that although about 80% of the patients attending the ORCI had received some formal education, less than half had even heard about cancer as a disease [8].

Something that became all too familiar to me during my time in Tanzania was the presentation of patients with extremely advanced disease. In the same study mentioned above, nearly 45% of the patients at the ORCI felt stigmatised about their disease [8], which was a significant factor in preventing patients from consulting. Another reason for patients presenting late in their disease was the use of a herbalist or traditional healer, which over 30% of patients admitted to doing before attending hospital, and 4% of patients thought their problems were due to charms [8]. Once again, the problem of traditional medicine is brought to focus.

Furthermore, despite being highly curable with relatively simple, inexpensive regimens if diagnosed early, paediatric cancers are among the most dismal in terms of overall survival [9]. Postulated figures for 5-year survival among children in Tanzania is in the region of 5-10% [9]. There are no formally trained paediatric oncologists in Tanzania, and there is typically no expertise in the histological diagnosis of paediatric malignancies, with delays of up to one month for pathology reports across Tanzania [9].

Having painted a somewhat bleak picture, I want to present a few cases that show evidence of the strength of a handful of healthcare workers, who are determinedly working together to provide care for cancer sufferers. One particular case which stands out for me, is that of a 7 year-old boy with Burkitt’s lymphoma. I met this patient on the male oncology ward, just as the nurse was preparing the chemotherapy. As she came onto the ward, the boys all leapt into their own beds, and this one child sat waiting to receive his toxic drugs. The nurse connected his cannula to an infusion of cyclophosphamide and left, there was no conversation between the two. I was so saddened to think of this poor child going through the process alone. I was reflecting on the times I have spent at home in the chemotherapy department, and the support that the patients received at such a difficult time. I found it very hard to comprehend such a small child going through the treatment alone, and I tried to find ways to keep him amused. The experience was definitely a sad one, but in many ways this child was lucky to be one of a distressing minority actually accessing the healthcare he required. When I asked the oncologist whether the boys were allowed to go home between chemotherapy cycles, he answered no. He explained to me that if he let the parents take the child home, it would almost certainly result in them not returning for the next treatment. I was relieved to see someone taking responsibility for the children’s welfare.

There are so many interesting and thought-provoking cases and experiences that I could write about, but I will finish this report with the case of a 70 year-old male, who presented with an extremely advanced carcinoma of the eyelid. The lesion was at least the size of a small mango. The first time I saw this gentleman, the lesion had been biopsied and was bandaged. The overall opinion was that there was no further treatment that could be provided for him at Bugando, and he was to be discharged. It was later decided that if he was able to receive some radiotherapy, the lesion may be amenable to surgical removal. However, radiotherapy is not available at Bugando, and the patient could not afford to make the journey to the ORCI in Dar-es-Salaam. I thought that this would be the end of the case. However, over a week later, another medical student from Hong-Kong who I had met in Tanzania informed me that the patient had been transferred to the ORCI to receive his treatment. Apparently, the oncologist at Bugando had paid for the patient’s care with his own wages. I understand that this is not a sustainable solution to the problem, but it certainly reinforced my belief that the makings of a dedicated oncology team in Tanzania are present, and it is only a matter of time before cancer care in Tanzania becomes recognised as one of the major specialities.


References

1. Tanzania national website; Health [online]. Available at http://www.tanzania.go.tz/health.html. Accessed on 08.07.10
2. The directfund foundation [online]. Available at http://www.directfund.org/. Accessed on 08.07.10
3. Shiner A. Shaping healthcare in Tanzania – who’s pulling the strings? The Lancet 2003; 362: 829-830
4. Global cancer facts and figures 2007; American Cancer Society [online]. Available at http://www.cancer.org/acs/groups/content/@nho/documents/document/globalfactsandfigures2007rev2p.pdf. Accessed on 09.07.10
5. World Health Organisation; National Cancer Control Programmes [online]. Available at http://www.who.int/cancer/nccp/en/. Accessed on 09.07.10
6. Shetty P. Twalib Ngoma: Creating cancer care in Tanzania. The Lancet 2008; 371: 1657
7. Louie K.S., Sanjose S et al. Epidemiology and prevention of human papillomavirus and cervical cancer in sub-Saharan Africa: a comprehensive review. Tropical Medicine and International Health 2009; 14:1287-1302
8. Kazaura R, Kombe D et al. Health seeking behaviour among cancer patients attending Ocean Road Cancer Institute, Tanzania. East African Journal of Public Health 2007; 4:1
9. Ribeiro R.C., Steliarova-Foucher E et al. Baseline status of paediatric oncology care in ten low-income or mid-income countries receiving My Child Matters support: a descriptive study. The Lancet 2008; 9:721

Guy in Ghana

Tuesday, April 27th, 2010

From Leeds to Ghana

Childrens ward with newly donated mosquito nets Childrens ward with newly donated mosquito nets

I intercalated in International Health, researching health issues of explosive remnants of war and health education in Liberia. I was exposed to the health service in a war-torn country, becoming increasingly aware of the issues of communicable infectious diseases. With a desire to continue my understanding of health care and communicable diseases I decided to pursue an elective in Ghana. The health service is substantial enough to provide a range of medical and surgical care, and provided me with a way to learn how communicable diseases are managed in countries with high prevalence but low facilities.

Students who decide to undertake an elective in Ghana usually spend the majority of their time in Accra (the capital) or one of the larger cities. This didn’t appeal to me, aiming for a more rural experience of medicine in Ghana.

I worked in two hospitals in the Eastern region of Ghana, serving over 2 million people, the Dr-Patient ratio approaches 1:32,000.1

My first month was at Kwahu Government Hospital, Atiebe. It is a mid-sized district hospital with four fulltime doctors. It provides wards for children, adults (medical and surgical), gynaecology, maternity and labour as well as full outpatients and casualty services. There is good national health insurance coverage in the area with about 70% of patients in the scheme.

The remainder of my time was in the under-developed Afram plains district of Ghana in Donkorkrom town. This was further away from the main transport links (including a four hour boat ride) and classed as a rural hospital. With 74 beds and two doctors, there was demand for it to cover the same services as Kwahu hospital with a higher patient load and fewer staff.

Kwahu Government Hospital

Theatres in Kwahu Theatres in Kwahu – From caesarian to thyroidectomies

My Kwahu experience was outstanding! It exposed me to common medical complaints in Ghana, a far cry from the “norm” in the UK. Experiencing ward rounds, assisting with patient management plans, assisting in theatre, observing outpatient clinics, running rural health clinics, and actively sharing responsibility and management of patients in A&E was exceptional learning. There was structure and supervision at all times with good feedback on performance and the opportunity to practice skills.

On reflection, it is obvious that resources are stretched. Although trained, lack of equipment means that procedures cannot be performed (e.g. LP’s/ECG). I was particularly concerned during my time there with the provision, and prescribing of analgesia and oxygen. Patients would rarely receive pain relief in hospital due to its short supply, and no analgesia at all available on the maternity wards.

With such a high demand for beds, better pain management availability for doctors would free up hospital capacity.2

Obo Clinic Week

Obo clinic week Obo clinic week – Head nurse leads the way

Arranging to spend a week in a rural clinic gave me an interesting whilst shocking insight into rural medicine. Run without input from doctors, complicated asthma, diabetic and communicable disease cases are managed by junior nurses.

I felt I technically worked as a GP in this setting, seeing 30-40 patients a day. I was anxious and reflected on the ethical issues of a medical student giving this sort of service. I received support from the doctors at Kwahu who facilitated the experience through regular contact. Whilst gaining unbelievable experience, I became aware of the crucial need for team work.

Donkorkrom Presbyterian Hospital

Venturing across the Valta to Donkorkrom Venturing across the Valta to Donkorkrom

I arrived in Donkorkrom to find one doctor on leave and one sick with Malaria. There was pressure to act as a “qualified doctor”, undertake ward rounds, make clinical decisions and run outpatient clinics. I quickly learnt to decline to make decisions where my medical experience was insufficient. I spent the majority of my clinical time running outpatient clinics alongside a Medical Assistant (nurse practitioner), with a team of nurses, nursing students and a mobile phone link to the malaria struck doctor! Despite an exciting experience, on reflection, the pressure of numbers of patients and lack of doctors leads to a feeling that the quality of patient care was sub-optimal. Wards were overcrowded; outpatients would run into the late evening, with doctors (and med-students) working 14-16 hour days.

Donkorkrom is funded by international organisations, relying on overseas donations. Many of these donations are physical items, such as ultrasound machines or dressing kits, however other items such as antibiotics and nebulisers are desperately needed.

Reflection

I really enjoyed the time I spent in rural Ghana, although not recommended for the faint hearted. I gained considerable experience working as a medic and believe that it improved my clinical decision making and highlighted areas in my medical knowledge that are good but also areas that need work.

I learned the importance of knowing your competency level and the need to seek senior support when stepping outside this. Team work was crucial to the success of clinical decision making.

Working in another healthcare system has helped me understand the different demands placed on financially stretched systems and the needs for prioritisation. These skills are transferable to foundation training. My general confidence in preparation for the work place has been greatly improved.

I succeeded in working in a different cultural, social and religious medical system and experienced the strains on that system. My knowledge of the healthcare of communicable diseases, where diseases are rife and resources limited has improved. I worked with a vast range of medical specialties and feel that the experience of making diagnoses, developing management plans, and seeing patients recover, has made me more confident in my own knowledge and abilities.

References:

1. Ghana Health Service (2008) Website: Regional Services – Eastern Region. Available online: http://www.ghanahealthservice.org/region.php?dd=5&region=EasternRegion [Last accessed 29.11.08]

2. Moller A, Pedersen T. (2006) Evidence-based Anaesthesia and Intensive Care. Cambridge University Press

Ewan Barron is currently an FY1 Doctor at St James’ University Hospital
ewan.barron@doctors.org.uk

Obstetrics and Sexual Health in Rural Namibia

Tuesday, December 1st, 2009

Within medicine I am interested in women’s health and sexual health, particularly in sub-Saharan Africa. Having spent a previous summer in the busy labour ward of Bwaila (formerly ‘Bottom’) Hospital in Malawi’s capital city, I aimed during my Year 5 elective to experience developing world obstetrics, in a rural setting.

Beautiful terrain- lo resA Beautiful View

Namibia is a peaceful country – relatively safe to travel in – and English is widely spoken in the North. Albeit a developing nation, urban areas are well developed, and the government medical system is modern and capable. It interested me to see how a rural hospital worked within this infrastructure.

Andara Catholic Hospital

Andara Catholic Hospital-lo resThe Hospital

Andara is a remote bush village with thatch-roofed homesteads between sand tracks, acacia trees and long grasses concealing cobras, pythons and black mambas. There is no bank, post office or shops. Two hundred kilometres from the nearest sizeable town, Andara Catholic Hospital serves nearly 30,000 rural people, with capacity for 120 in-patients. Four doctors share responsibility for the wards (male, female, paediatrics, maternity and TB) and the Voluntary Counselling and Testing (VCT) centre for HIV patients. A weekly VCT outreach to five clinics in the surrounding 100km endeavours to identify and treat HIV positive individuals who would not otherwise travel to the main hospital. Each morning the doctors meet to discuss cases the previous day’s admissions. After their ward rounds, the doctors act as general practitioners, seeing 50-100 patients on a first come first served basis, and are also on-call for emergencies in labour ward and casualty.

Primary care centre-lo resThe Hospital’s Primary Care Centre

I noted frequent frustrations with limited availability of resources, and language barriers. The doctors, who were from neighbouring countries, did not speak the many local dialects fluently but many nurses were able to translate. Andara’s doctors are not trained specialists. However, they are remarkably skilled generalists and the breadth of their competence impressed me. Competencies of the most junior doctor, who graduated from the University of Zimbabwe four years previously, included obstetric and general surgery, general and spinal anaesthesia, multi-drug resistant TB management, and manually reducing fractures.

Obstetrics

There were around four deliveries each day – a tiny proportion of deliveries taking place in this bush district with a great many traditional birth assistants. Ante-natal care was available and HIV screening for prevention of mother to child transmission (PMTCT) was heavily promoted.

The labour ward may seem, to a western eye, a frightening place for an undignified labour and delivery. The open-plan room afforded little privacy for women labouring without the support of family members, or the comfort of analgesia. Foetal monitoring was carried out effectively using Pinnard stethoscopes. Ventouse equipment was available for vacuum assisted deliveries. Routine practice included episiotomies in primigravida women and active management of the third stage of labour. Caesarean sections were only indicated in emergencies.

Theatre-lo resTheatre

Skin to skin contact and breast-feeding were not part of immediate post-natal management. Neonates were weighed, cleaned, wrapped and given a vitamin K injection and tetracycline eye ointment before being returned to their mothers.

With opportunities to deliver babies, repair episiotomies, and assist in theatre, I appreciated that the doctors supervised me carefully, particularly when delivering a breech baby.

I found women labouring in Namibia to be different from those I have encountered in the UK. Despite the norm of labouring without analgesia, their expression of pain was minimal. During contractions I noted most women closed their eyes and rocked their hips from side to side, occasionally letting out a groan or ‘eee’. I was struck by this apparent resilience and tolerance of pain, but I also wondered whether some women were quiet because they felt alone and unsupported. Although a midwife was always present, rapport with and moral support for women was not so evident.

Sexual Health

Contraception- lo resContraception Methods

In 2008 the Principal Medical Officer carried out a survey (1) of 251 adolescent females attending clinics for family planning advice. It revealed that the majority had started sexual intercourse by 15 years of age. During the preceding 12 months, 12.2% had had more than one sexual partner, and only 47.3% of respondents had used condoms at last sexual intercourse. Contraception is available free of charge in the hospital and clinics. Heavy promotion of barrier contraception in adolescents is primarily for the prevention of HIV. A qualitative study conducted in northern Namibia in 2005 reported misunderstandings about HIV and condoms (2); for example that infected people no longer have to protect themselves in sex and others believed that the gel inside condoms contains HIV.

Some men living further away in the bush would not travel to Andara to get condoms, but did attend the hospital to be circumcised – a procedure they were aware of as a strategy for preventing HIV transmission. Male circumcision may reduce the risk of HIV transmission in men by 60% (3) and in 2006 it was projected that full coverage of male circumcision in sub-Saharan Africa could prevent about 5.7 million new HIV infections and 3 million deaths over 20 years (4).

Conclusion

This elective experience was fantastic, providing opportunities to learn about tropical diseases and to develop clinical skills in obstetrics. I was also interested to learn about studies that have been conducted in northern Namibia, relating to sexual health and the prevention of HIV transmission. I was encouraged that it is possible to conduct research, promote change and carry out audit even in an environment where monitoring patient follow-up can be difficult.

Laura Stirrat has just completed her final year of medicine at the University of Edinburgh
L.I.Stirrat(at)doctors.org.uk

References

1. Ntumba A. Assessment of the knowledge, attitudes and associated behaviours of female adolescents and contraception in Northern Namibia. Andara Catholic Hospital, Namibia. 2008.

2. Namibia Government. Report of the 2007 National HIV Sentinel Survey. Ministry of Health and social services, Windhoek, Namibia. 2008.

3. Auvert B et al. Randomised controlled intervention trial of male circumcision for reduction of HIV infection: the ANRS 1265 trial. PLoS Med. 2005. 2(11);2298.

4. Williams BG, Lloyd-Smith JO, Gouws E, et al. The potential impact of male circumcision on HIV in Sub-Saharan Africa. PLoS Med. 2006. 3:e262.

Surgery at Mount Meru Hospital

Tuesday, September 22nd, 2009

Mount Meru is a 450-bed hospital located in Arusha in northern Tanzania. I was fortunate enough to spend a vacation period working in the surgical department at the hospital.

The surgical department consisted of four surgical wards and a major and a minor operating theatre. The theatres were a stark contrast to what I had experienced in Western surgical units with only one anaesthetic machine to induce patients and one autoclave with which to sterilise the surgical equipment. Despite the lack of equipment the surgeons were more than capable and were keen to teach in English during operations and on ward rounds. The surgical team consisted of the Chief of Surgery and five trainees at various stages of their training. All members of the surgical department were very welcoming and friendly and were keen to hear about how things differed in Europe.

A typical day began with the walk in to the hospital from where I was staying through the town of Arusha. Local vendors and street sellers were always keen to try and sell things to the ‘Mizungos’ (white people) and would often follow you with their wares in the hope that you might make a purchase. Having made it to the hospital the day usually began with a ward round or theatre list.

Paediatric BlockThe paediatric block

The Wards

Ward rounds were conducted in a mixture of Swahili and English. Patients had little privacy on the wards with no dividing curtain between beds and twenty to thirty beds crammed into each ward. Infection control was an issue with no hand-washing facilities or alcohol gel and it was not uncommon to see birds flying around the ward. Wards were divided into male, female, paediatric and septic. The septic ward mainly consisted of burns patients. Burns is a major problem in Africa with many women and children living with open fires used for cooking. There is also still an element of mob-law with fires and scolding oil used to punish crimes. Without the facilities and technology to prevent infection and replace fluids, burn injuries are invariably life threatening and management usually comprises with just covering the wound and providing basic fluid support.

Together with burns, trauma made up the vast majority of surgical inpatient cases. Causes of trauma ranged from motorcycle and road traffic accidents to gunshot wounds and developmental conditions such as osteogenesis imperfecta. During my time on the surgical ward a riot had broken out in a neighbouring town and several patients had been admitted with shotgun wounds and injuries caused by explosive devices.

The mainstay of fracture fixation on the wards was traction. Traction consisted of bags of rocks attached by string to the legs of the patients and hung over the end of the bed. This method was effective but patients were bed-bound for several weeks and traction often had to be adjusted each morning due to patient movement.

Due to the living conditions of some of the patients discharge from the wards was a problem. There were no occupational therapists in the hospital and one patient, who was paralysed following a mining accident, had been in the hospital for over two years as he could not have received adequate care had he returned to his village.

Mount Meru WardOne of the wards

The Theatres

The majority of my time at Mount Meru was spent in the operating theatres. I was lucky enough to assist during an appendicectomy and also got to experience open reduction internal fixation, ectopic pregnancy, hernia and pin-removal procedures.

Theatres were not sterile by Western standards but doctors and nurses did their best to maintain a c environment. Lack of resources also meant that equipment such as suture material was often of poor quality and it was not uncommon for sutures to break during wound closing. Muscle relaxant used prior to abdominal procedures was also of poor quality and it was common for the surgeons to have to search for structures such as the appendix while operating as the bowels had been allowed to move without adequate relaxant. Fluid management was also a major concern as there was no blood available for transfusion and only saline for resuscitation.

Patients had to pay for operations and there were several occasions when a patient had not provided adequate funds and their operation had to be postponed. This was difficult to watch and certainly made me appreciate healthcare provided by the NHS.

Despite the obvious contrast in equipment and funding to surgery in Europe the competency and training of the surgeons themselves was of a very high standard. The team were knowledgeable of procedures and complications and were able to swiftly deal with problems caused by poor equipment or lack of resources.

Conclusion

Working at Mount Meru was one of the most challenging and rewarding experiences of my medical career to date. I feel that I was able to learn much from the surgical department and have certainly captured many of the principles and difficulties of surgery in a developing country.

Alexander Young is a final year medical student at the University of Bristol in the UK
alexanderfyoung(at)googlemail.com

Emergency: Sierra Leone

Tuesday, September 15th, 2009

IMGP4620The Surgical Centre in Goderich, just outside Freetown

Sierra Leone. Those two words typically conjure up images of child soldiers, a country torn apart by war, and open pit diamond mines opening up gaps in the jungle. Today, the country is on the way back and holds an excellent opportunity to see a medical non-governmental organization in action while still a medical student.

I have a particular interest in international emergency medicine and the work of Emergency, an independent, neutral and non-political Italian organization turned out to be a great fit and first experience in NGO work. The organization provides medical and surgical treatment, for free, to civilian victims of war, landmines, and poverty. The goal of Emergency is to build hospitals specifically dedicated to war victims and then to train national staff and hand over the health centres to local health authorities as soon as they are deemed to be self-sustainable.

In terms of setting up the observership it was done on the ground in Sierra Leone. I flew into Freetown and then took a small community bus out to the Surgical Centre in Goderich, approximately twenty minutes outside of the city centre. I was introduced to the Medical Coordinator who explained the limitations of being a medical student in an NGO environment but strongly encouraged me to ask questions and gain understanding of how the organization worked.

The hospital itself was a very impressive structure, completely self-sustaining, with its own water supply and electricity. These two factors are essential as the infrastructure in Sierra Leone is still not stable enough to ensure that surgery and sterilization can continue uninterrupted while connected to the national electricity and water grid.

The war in Sierra Leone saw mass displacement of civilians and resulted in over 70,000 deaths in a population of 4.5 million persons. Of particular note were the large number of people that were deliberately mutilated by child soldiers wielding machetes. Charles Taylor the previous President of Liberia is on trial in the International Criminal Court at the moment for his supposed involvement in this barbaric aspect of the war. The Emergency program began in 2001 for war victims and it was at this stage that it added orthopaedic and surgical emergencies to its program. In 2002 a Paediatric Outpatient Department was constructed to treat the large number of children with anaemia, malaria, and respiratory infections that were arriving at the centre.

My experience was split between the paediatric outpatients and the emergency room where patients would either be seen for emergency cases or referred to the main public hospital if they were non-emergency patients. On average 1,300 children are treated every month.

In order to treat this large number of paediatric patients the outpatients was incredibly efficient. The children would be seen, investigated, and seen for the follow up with completed investigations in the same day. In a country where many mothers and fathers would have to travel long distances having an examination, laboratory investigations, and a follow up interpretation with pharmacy on hand is a blessing. The lab was rudimentary but the key investigations for anaemia, sickle cell, and malaria could be done within two hours allowing the children to be prescribed treatment in the afternoon of the same day they were first seen.

In the emergency side of paediatrics there are an inordinate number of children that are brought in with caustic soda ingestion. This is causes severe oesophageal burns and is the result of families making soap at home without proper supervision.

In terms of emergency presentations in the Accident and Emergency department the presentations were varied and complex. There are a large number of traffic accidents in the country and many patients are literally carried into the department and dropped onto the floor for treatment. In addition there are plenty of Colles fractures along with the weird and wonderful. However, you have to be prepared to see the sad and distressing cases. One of the most depressing moments was seeing a small child who had a line placed and removed in a peripheral hospital over 3 weeks ago which had become infected. The child’s arm was unsalvageable and with the huge stigma associated with amputation after the war the decision by the families to amputate and save life or allow death to follow is not as simple as it would seem in the developed world.

Overall, the decision and work involved in setting up the opportunity to watch a medical NGO on the ground and in action gave me an excellent opportunity to not only see the challenges of working in a high volume, high stress situation but also the amazing difference that aid money can make and how high quality health care can be provided at a fraction of the cost incurred in the developed world.

Paul Dhillon is a final year medical student at the Royal College of Surgeons in Ireland
paudhillon(at)rcsi.ie