WARWICK MEDICAL SCHOOL: COHORT 2012
MEDICINE IN ZAMBIA, 2015
Chikankata Mission Hospital
Medicine in Zambia
I knew that I always wanted to undertake my elective in a third world country before starting Medical School where medical conditions are completely different to the UK. It was after talking to some friends who had visited Zambia on medical elective that made me decide to go there.
Figure 1: myself along with my colleague and another medical student with two midwives
I met all of my personal elective aims (appendix A) during my time at Chikankata Missionary Hospital. The hospital serves a catchment area of over 100,000 people but also receives many referrals from all over Zambia. It is a 200-bed hospital, with only five doctors, that is run by the Salvation Army on behalf of the Republic of Zambia Government. A major setback to the hospital is that there is still a significant gap between funding from the government and Salvation Army and the income needed to run the hospital. As a result, the hospital has to be minimalistic on medical resources.
Nearly complete availability of X-ray, CT/MRI and bloods tests on demand \ Only has one X-Ray machine, no CT/MRI, small number of blood tests available
Patient notes kept by hospital \ Patient keeps own notes
Items such as tourniquet, drug bottles are disposable \ Items are cleaned
Invasive procedures carried out with anaesthesia if necessary \ Many invasive procedures are undertaken with patient ‘cooperation’ rather than anaesthesia
Meals are provided by NHS for inpatients \ Family has to provide own meals for patient
Patient’s with infectious diseases are put in side rooms to reduce infection \ Infectious patient’s remain on the general ward
Large selection of drugs available as dictated by British National Formulary, National Institute of Clinical Evidence and hospital formulary \ Approximately only 15 drugs available
Bedside equipment widely available \ One fully working blood pressure cuff for the entire hospital and no ECG machine
Storage of used materials secure e.g. sealable plastic sharps containers \ Sharps stored in open cardboard containers
Locals who live around the Mission have to rely on this hospital as the next nearest hospital is in Lusaka, which is 125km further north. The comparisons outlined above have made me appreciate the vast number of resources the NHS offers and also the cost associated with these resources. Subsequently I will only order investigations when I know they could alter the management plan. I also learnt from the Zambian doctors that due to only minimal investigations available, a thorough history is imperative in order to make a logical diagnosis. I feel that this has improved my ability in questioning patients when taking a history back in the UK.
I witnessed an insertion of a chest drain, removal of ganglion cysts within the hand, amongst other procedures, that were undertaken under patient ‘cooperation’ (i.e. no anaesthesia) – a stark contrast from how these would have been done in the UK. I have learnt the importance of prescribing sufficient peri-operative anaesthesia.
Outpatient appointments took place with a doctor and a nurse who would speak the patient’s language (there were around six different languages spoken!). Consultations were frequently interrupted by hospital nurses coming in to be assessed by the doctor trying to convince them they were ill and needed time off work – something that I would never see in the UK. This has reinforced to me how much patient confidentiality and relationship with the patient is paramount. I have also learnt the importance for a competent translator because at times even the nurses found it difficult to translate what the patient was saying into English.
I became aware of some of the traditional Medicine that locals would use on themselves in order to ‘cure’ themselves. As Africa has a high amount of HIV I became more aware of the biological, psychological and social impact of HIV diagnosis upon patients and its complications. I saw a man suffering from HIV with Kaposi’s sarcoma – his right leg was completely infested with purple papules. Due to his cultural belief he covered his leg in mud to cure his condition. This was upsetting for me to see because of his level of distress and incomplete awareness of HIV and the affects it had on his life.
I also observed many patients who believed that if part of their body was hurting, then cutting the affected area and inserting an herbal remedy within the cut would help. This made me appreciate practising ‘Western Medicine’ based upon scientific evidence and less emphasis on potentially harmful alternative therapies. Additionally, patient education is key to involving patients in their own care and subsequently improving patient outcomes.
I worked alongside two Danish and one Dutch medical student who were all in their final year at medical school and hence I was able to increase my medical knowledge, especially management and clinical skills from discussion with them. With the help of a nurse translator and another medical student I clerked patients. This improved my history taking, examination and most importantly likely differential diagnoses. I attended ward rounds where I was put in charge of writing in patient notes – a skill that I will need when I start as a foundation year doctor. I spent my free time with the other medical students and learnt about foreign medical education systems and their general approach to Medicine.
I was made more aware of the importance of breaking bad news in the best way possible. I witnessed a 37-year-old female being told she had confirmed lung cancer who had been under dual care with another hospital. The doctor gave no warning that the patient was going to receive bad news and the patient was given no opportunity to express their feelings. I feel that this left the patient unsupported and upset. In comparison, before bad news is given in the UK a protocol of SPIKES (Setting up, Patient’s perception, Invitation, give Knowledge, patient’s Emotions) is undertaken. This has made me appreciate this protocol even more.
I was lucky enough to attend a number of Doctor’s outreach trips where one doctor along with six nurses visited villages within the African bush. As the visit only happened once a month there were usually lots of locals needing medical attention. The main conditions seen were anaemia, diabetes, tuberculosis and HIV complications. The latter two are conditions not normally seen in the UK. I was able to ask the Doctor questions when needed which broadened my medical knowledge of these areas.
Not only did I learn about traditional Zambian culture and the main language of Tonga but due to working inside a Mission I also learnt about the Salvation Army and their work worldwide. Before starting at the hospital I was introduced to the ‘Captain’ who overseas the whole running of the Mission (it is very much a hierarchical system). We were also lucky enough to meet the chieftainess of the Mission who is the equivalent to our Queen of the local tribal area. She believes she is a rainmaker and constantly knows everything that happens on the Mission.
My time in Zambia experiencing third world Medicine was an unforgettable one. I have gained in confidence, medical knowledge, and understand more clearly the importance of a good doctor-patient relationship, confidentiality and patient education.