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Elective Report Meredith Bowles Introduction When planning my elective, I knew I wanted to go somewhere in Africa and see medicine in the 3rd world. My preference initially was towards Kenya and Rwanda, but when I started making inquiries it was a doctor at a small clinic in Mpwapwa, Tanzania who first offered me a place. She proposed a tempting mix of inpatient, outpatient and community work, which was precisely what I had had in mind. So it was that I ended up in Mpwapwa, a market town of about 30 000 in the centre of the country, approximately 7 hours west of Dar Es Salaam. I was based at St Luke’s Clinic, a missionary run outpatients facility set up and run by a British doctor who has lived in Mpwapwa with her family for nearly 15 years. The national language in Tanzania is Kiswahili. More educated Tanzanians speak English as well, so most nurses and all doctors have a reasonable grasp of the language. However, in the more remote villages some of the older inhabitants speak only the local variation of Kiswahili, in our area called Kigogo. These language differences meant that without a translator it was impossible to communicate meaningfully with patients. Since people with a good enough grasp of both languages were primarily healthcare professionals themselves, it was rare for us to take the lead in a patient’s care. Instead we observed more and the doctors we shadowed kept us informed as to what was going on. My working week was split between the difference aspects Dr Tarling had promised. I spent 2 days at the clinic, sitting in with her outpatient consultations. 2 days a week I spent at the local government hospital, and the last day on “Baby Safari”. The Clinic St Luke’s Clinic is a small set up, with a staff of 2 doctors, about 7 nurses and two laboratory technicians. It is open Monday to Friday from 0830 till 1600. As well as the main clinic there is a 4-bed maternity ward (plus delivery room) which is open and staffed by a nurse 24 hours a day, 7 days a week. An anaesthetic room is currently under construction so that caesarean sections will be possible onsite. The clinic has facilities for basic blood, urine and stool tests, a small pharmacy and an ultrasound. HIV testing is also available and the clinic employs a full time HIV counsellor. Costs are subsidised by the missionary organisation, but patients must contribute standard amounts towards their treatment. For example, patients pay 200 shillings to see the doctor (equivalent of approximately 8p). Patients started arriving from around 0730 and a number card system was used to organise appointments. Typically one doctor would see between 30 and 50 patients in a day. Complaints were massively more varied and severe than one would see in an equivalent British setting. This year had actually been a very good year for the rains which meant that people’s crops had done better (most people in the villages are subsidiary farmers) meaning that there was more money available to spend on healthcare. Consequently a higher proportion of patients were presenting with chronic complaints that they had been unable to afford getting seen to in previous years. The most common diagnoses however were malaria and worms, and it was not long before I picked up the Kiswahili words for common symptoms and commands used during the examination. Baby Safari Baby Safari was always a fun day. A car-full of nurses would leave the clinic around 10 and drive to one of the remote villages. Gradually women and children would congregate as the nurses set up. Under-fives are weighed, and growth is charted. Vaccinations are given to babies and all the pregnant women are examined and their progress monitored. Finally, women can come for contraception. The oral contraceptive pill is free, but most women choose to pay for a depot injection – the men tend to by unsympathetic to the need for birth control (possibly because they’ve never seen labour) and this means that it can all be done without their husband’s knowledge. Hospital The local hospital was financed by the government and had more extensive facilities than the clinic. It had 8 wards each with approximately 8 beds, 2 theatre rooms, a maternity waiting home and some outpatient facilities as well. There was also a laboratory, x-ray machine and pharmacy. There were about 8 doctors, a number of nurses, admin staff, lab technicians and cleaners. I spent most of my time on the maternity ward. This was partly because I am particularly interested in obstetrics, and party because the most friendly doctor was covering the ward for my first couple of weeks there. Dr Chielo was a senior doctor whose English was impeccable. He was keen to teach and often took us to examine patients. He encouraged us to go into theatre where we saw a variety of different operations before the hospital ran out of sutures and all elective surgery was cancelled. The contrast between obstetric medicine in Africa and here in England was huge. If I learnt one thing from my elective it was that I never, ever want to give birth in Africa. It is not only the lack of resources mean that make it such a different experience for the women. The whole culture is massively different. Women are expected to make no “fuss” (ie noise) during labour, despite a complete absence of any form of pain relief. Staff are resolutely unsympathetic towards patients, and I saw nurses and doctors being simply mean to patients, saying that the woman was a coward, not pushing hard enough and if she didn’t try harder the baby would die and it would be her fault. These members of staff were perfectly nice at other times, but this example reflects a general attitude that could not be more different than in England. Medicine is massively paternalistic and patients are not expected to question anything about their diagnosis or management – that is if they are even informed of what these are. Doctors tend to have no regard for a patient’s dignity, often leaving them completely naked way after the examination has finished. I saw one doctor get a nurse to answer his mobile and hold it to his ear whilst he was in the middle of a vaginal examination. Needless to say I was horrified. I found this attitude very difficult. So often I wanted to simply comfort a patient, reassure them or just be nice to them, but the language barriers made this very difficult. I also spent time on the paediatric ward. I was surprised and by the range of problems that were prevalent. Malaria and pneumonia were high on the list, but also severe burns. When I asked why exactly this was, no one really had an answer. After a while living in the area however I realised some contributory factors: safety around the home is almost non-existent, and small children are supervised by older siblings, if at all. Consequently children have a lot of avoidable accidents. Conclusions I found medicine in Tanzania both massively frustrating and hugely satisfying. It is frustrating for a number of reasons. There is the simple lack of resources. There are limited investigations available, and the management options are small as well. It is often the case that you just can’t get the drug you need. Added to that is the perhaps more ingrained problem of their culture of medicine. There seems to be no concept of emergency, that they could make a difference. When someone dies unexpectedly in England the question asked is “Why? Who did something wrong?”. Whilst this is far from ideal as well, there are benefits. Practise is scrutinised and management strategies are changed and improved. In Tanzania if someone dies unexpectedly, no one asks those questions. Instead people say it was a “difficult case” and they were “unlucky”. This refusal to reflect on their own practise was maddening. I accept that in an environment where death is so much commoner because resources are so scarce, a different attitude to that which we adopt in England is necessary to get through the day. Nevertheless, I still found this very frustrating. On the flip side, medicine in such a context can be very rewarding. In such circumstances one is reminded that even the most basic of interventions can make such a huge difference. For example, you have a woman having big difficulty in labour. A caesarean is performed and both mother and baby survive. The wound is not neat, will probably get infected and the woman is now high risk in subsequent pregnancies, but she is alive. I found this side of medicine exhilarating and reminded me why I wanted to be a doctor after all.
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