To the Memory of             Luka Randić

 
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Introduction

I spent my elective period of January and February 2001 at Friends Lugulu Hospital in rural Kenya. In this elective report I aim to set out the objectives with which I left for Africa and discuss my experiences from that time, as well as how those objectives were addressed.

Objectives:

To experience healthcare in a developing country.
To learn a new approach to medical problem solving, one which cannot rely on complicated and expensive investigations.
To improve my clinical skills and abilities to make clinical decisions.
To learn about Tropical medicine.
To witness first-hand the effects of the African AIDS epidemic.
To discover cultural differences in patients’ perceptions of health and illness.
Challenge my perceptions of the “western” approach to healthcare.
Learn about Africa, patients and myself.

Although I have extensive experience of travelling in developing countries, I never experienced any kind of healthcare provision either through government or non-government agencies. I have never visited Africa before. I wasn’t really sure what I expected to find, but surely the approach to a sick patient could not be very different?

The Setting

The political instability and gross corruption encompassing a lot of African countries also affects the provision of healthcare. Kenya is relatively stable but has a large corruption problem in its own government. This also extends into the international agencies working in the country.
All these factors affect the ability of the average person in rural Africa to access adequate healthcare.

As the hospital was set in a rural population the vast majority of the local people are farmers. The area is quite fertile hence densely populated. Most of the farming is done for personal consumption and what little is left over was taken to the local market. The farmers are relatively poor but there seemed to be enough food and people weren’t starving, although most of the children were underweight.
A typical diet involves Ugali (corn flour mixed with water) and some greens. There is little protein in the diet as it is generally too expensive. They would only have some meat maybe once a week.

The majority of people do have access to relatively clean water from the hospital well but very few have electricity. Most houses are made out of straw and mud.

Malaria and typhoid are rife in the area. Most adults living at lower elevations have a degree of built up immunity to malaria. This however does not apply to children under five years of age or to pregnant mothers. People living in the higher elevations at about 7000 feet or higher on the slopes of Mount Elgon have no immunity to malaria as it is uncommon at those elevations.
Because most adults have a degree of immunity to malaria no one uses mosquito nets and it was really hard to convince pregnant mothers and babies to use them.

Kenyan healthcare

The healthcare system in Kenya is a government service running in parallel with the private sector, which is generally made up of mission hospitals ranging from small clinics to large medical centres. In addition to this there are traditional village healers who constitute the main source of healthcare outside metropolitan areas. They generally function as general practitioners, in that they are the first step in accessing healthcare for the local villager.
The traditional healers utilise local plants and “magic” or “spells” as methods of treating anything from snakebites and trauma, to indigestion. It is an ancient art that is passed down through the generations.

Government hospitals, like most government institutions, are riddled with corruption and under-funding to such an extent that hospitals lack the most basic of medication and equipment.
Stories of patients being brought to district hospitals in severe shock only for their relatives to be told to go and buy a venous cannula and some normal saline from the pharmacy in town and then come back are not uncommon.
Government hospitals sometimes lack doctors and are staffed only by a few trained nurses, as the doctors go and do their private clinics on hospital time.
Such stories are almost unthinkable in our society where we generally live in ignorance of how lucky and privileged we are to have a reliable access to reasonable healthcare.

At the Friends Lugulu Hospital a day at the hospital would cost about Ł3.50, which is a lot of money for a rural farmer. This excludes any investigations or treatment. A chest x-ray was about the same and by the time you have added up the cost of a venous cannula and some fluids the bill would significantly indent a framer’s savings.

If the patients were unable to settle their bill after discharge they would have to remain in the hospital compound and sleep out on the veranda or the ward floor. They would do so until their family could gather enough money to pay the bill through either selling their possessions (livestock or land) or borrowing.
It is not uncommon for these “discharge-ins” to remain at the hospital for few weeks. Because of this financial pressure on the patients, there was also immense pressure on us as doctors to discharge them as soon as possible. Their families needed the husband or wife back so they could continue to work the land and take care of the family.

I remember the story of one young mother who got very sick just after delivering her first baby and was hospitalised for a long time without her child. The child was fed at home on cow’s milk while the mother was in hospital. In the mean time the mother’s breast milk dried up. Then the child got sick and came in with the mother, during which time the cow at home died, leaving the baby without any source of milk. The family was too poor to buy another cow or to keep buying milk.

The only free treatment available was tuberculosis triple therapy, which was sponsored partly by the government and partly by the WHO.

AIDS in Africa

Africa is currently suffering an epidemic of HIV infection. The infection rates in Kenya are around 15-20% of the general population. Other countries for example Zambia are currently running rates as high as 40%.
The western world is slowly coming to terms with HIV and AIDS. We have good awareness of the risks and how to prevent them as well as the medical infrastructure wealth to be able to care effectively for the affected patients.
In Africa however AIDS is still a taboo topic. Although the governments and WHO are working hard on the awareness and prevention aspects, they do not have the financial capability to afford to care for the HIV patients. They also lack the necessary medical facilities for extensive follow-up and effective treatment. For instance, very few places on the whole continent have to facilities to monitor CD4 counts.

The situation is also made worse by the expensive anti viral drugs. It is only the very few of the African rich that can afford the treatment while the rest (the majority) have about 12 months to live from diagnosis.

It is considered rude to ask patients if they’ve had an HIV test or if they think they might have been exposed to HIV. It is not discussed within the families and when the people eventually die the family only say they died from “a very quick illness”.

The most readily available test for HIV is the Elisa test. This is not nearly specific enough to avoid false positives when compared to the Western Blot test that we use. This has a huge impact on the psychological well being of the patients and their families as they are discharged home with a diagnosis of AIDS. Unfortunately the Western Blot, at $60 per test, is out of reach of most Africans.
Also the fact that it is possible to test the people in the “clear window” period, when there are no antibodies yet, has severe implications for all the donated blood. There are no figures as to how many people are infected each year through blood transfusions, but I am sure it is a significant amount.

The lack of adequate medical facilities and financial capability to monitor and treat AIDS points to the fact that current western answers to AIDS are presently not applicable to Africa.

The Hospital

Friends Lugulu Hospital is 100-bed mission hospital located in a rural, densely populated area of western Kenya; at the foot of Mount Elgon. There are approximately 6000 new admissions, 1000 deliveries and 25000 outpatient visits per year.

The hospital consists of four wards – male (medical and surgical), female (medical and surgical), paediatric and maternity. There is an outpatient department with and attached minor theatre, as well as a large operating theatre for major surgery

The major causes of morbidity and mortality are infections (e.g. malaria, gastro-enteritis, and pneumonia, TB, typhoid and AIDS), pregnancy related problems (high-risk obstetrics) and trauma (penetrating e.g. machetes and blunt e.g. road traffic accidents).

There are three medical doctors working at the hospital – two American physicians (one trained in paediatrics and family practice and the other in family practice) and one Kenyan-trained physician with specialist training in surgery.

As most doctors in rural areas, all three doctors perform emergency surgeries which include emergency C-sections and laparotomies. The scope and variety of work the doctors have to do is immense, purely because if they don’t do it, it won’t get done. Their patients cannot afford to go to specialist centres.

The hospital is a mission hospital built at the beginning of the seventies and supported by Friends United Meeting. This is an American Quaker organisation, which sends out missionaries to provided spiritual guidance as well as other facilities like education and healthcare to developing countries.

All the staff, but less than half the patients, speak English and there is generally always someone available to translate from Kiswahili or Bukusu which are the local languages.

The hospital facilities include an x-ray machine (only powerful enough to take films of extremities – but used for everything) and a donated ultrasound machine (which only one doctor taught himself to use for the most basic of obstetric investigations). Other available investigations are limited to a malaria smear, Hb, white cell count and differential, ESR, urine dipstick, blood glucose, CSF culture and microscopy, pregnancy test, and sputum for AFB’s.

Any other investigations require referring to a town about 200 km away. This includes things from liver function tests to CT scans. Very few people could afford any of these referrals so the patients are managed and monitored using only the doctor’s clinical skills of history taking and examination and the few available investigations.

The hospital laboratory makes their own sterile fluids that included Normal Saline, Hartman’s and Darrow’s solution.

Every time a patient requires a blood transfusion their relatives have to donate a unit of blood for every unit transfused. This is the only way the hospital could try and maintain its supply of blood. Unfortunately this cannot account for the different blood groups and we would regularly run out of the one blood group we would really need. In those situations we would send the realties out to round up as many blood relatives as possible to try and find a match.
In the local population there were very few Rhesus negative blood group carriers, which meant there is a scant supply of rhesus negative blood and most of the time the hospital didn’t have any in stock. This was a problem in trauma situations and when we had other rhesus negative patients in need of a transfusion.

The hospital has its own bore-hole so a relatively clean water supply is available -except during very dry spells. Electricity is available most of the time and the hospital has it’s own diesel generator for use in theatre as a back-up plan.

The Elective experience

During my time at the hospital I functioned effectively as a house officer or SHO and was a full member of the team. The three doctors were full of support and enthusiasm to allow development of my clinical skills as well as to teach me new ones.
Their attitude was that if I were happy and confident doing something they would let me get on with it.

As there were effectively three main wards (medicine, surgery and paediatrics) and maternity. I spent three weeks on medicine, three on paediatrics and maternity and two on surgery. In reality I covered the whole hospital and saw patients on all the wards every day. The experience was as broad as possible.

At the beginning when I arrived, the culture shock was great. First of all the lack of electricity for the first few days and the lack of running water for the duration of my stay there made it very difficult for me to settle in.
The hospital was unlike anything I had previously imagined and worlds apart form the shiny clean NHS (oh yes!) hospital I had just come from.

On all the wards there were two patients in each bed (sometimes that went up to three – one under the bed!) because it was so busy, and in the paediatric ward four people to a bed (two kids and two parents). The wards are just one long room with beds everywhere and people all over the floor. Because of the high incidence of diarrhoea and other infectious secretions the smell was intolerable at the beginning. This was especially true on the paediatric ward, as none of the babies there had any nappies. This meant there was a constant flow of diarrhoea and urine on and around every bed (vomit and spit (culturally acceptable) were no strangers either). Both the mother and the babies were covered in all manners of secretions. In such an environment you would think it imperative to wash your hand between patients - if only that there were enough water.

The normal working day would start at 8am with a post call ward round, where everyone would go around and see all the new admissions that came in over night. Then the three doctors would go each go around and see their particular wards and conduct ward rounds. The hospital was split into medicine, surgery, and paediatrics and maternity.
On the ward rounds I would see patients, decide on their management, write follow-up notes and prescribe any necessary medication or treatment. All the hospital staff treated me as just another doctor.
In the first week or so I ran things through the other doctors most of the time, but gradually as I gained experience and confidence I was happy doing the ward rounds on my own and undertaking minor procedures without supervision.

The learning curve was tremendous and I quickly picked up the practical procedures and became very proficient and confident. Procedures like lumbar punctures, thoraco- and paracentheseis, incision & drainage of abscesses, joint aspirations, dilatation & curettage for evacuations, surgical toilet and stitching were just a few of the ones I was able to practise. I would regularly assist in theatre and by the end was allowed to close every time. The experience was incredible. There was a also an advantage for others, -while I was doing this, the other doctors were freed up to see other patients in this very busy hospital.

I also felt that I had a lot to give back both the doctors and other hospital staff as well as the patients as I challenged the ways of delivering care and questioned some of the methods.
As the doctors there are relatively cut-off from peer review and novel ways of managing patients I felt like I had a lot to contribute.
The ward rounds would last for the best part of the morning and then whoever would finish first would start seeing all the outpatients that came that day. We would break for lunch at about 1pm until 2.30pm, during which time was the visiting period. In the afternoon, from around 2.30pm to 5pm we would spend time seeing new admissions and outpatients as well as doing any other jobs like minor operations.
At 5pm the working day would finish and whoever was due to be on call would be called until 8 am the next day.

Saturday was a normal working day and only Sunday was a rest day unless you were on call that day.

By about day 4 I was included into the on-call rota, which was 1 in 3, so I functioned as a first on call every third night. When on call, you would be on call for the whole hospital. One of the doctors would be on with me and would be there in case I needed any help or didn’t know what to do.
When on call we would do the evening rounds at 7pm and see any new admissions from 5pm and sort out any problems that needed attention.

The system for calling the on-call doctor was unique. There were no pagers and no telephones in the doctor’s houses. The only way of contacting us was in person so the night overall would send a little note via the hospital guard who would come and gently knock on your bedroom window until you woke up. The notes would sometimes be vague: “M.O. on call – please come review new admission” and other times more detailed and amusing: “Dr. On Call – Please come and review a patient who has just come in with head injury and machete through skull and brain”.

Because of the nature of presenting illnesses and the lack of good medical care was generally unavailable the workload was immense and at times very stressful.

Sometimes it was very difficult being the only doctor there and being the first at the scene. Lots of the children and babies died regularly from cerebral malaria and meningitis. On average we probably had one child die every day.
This was a big shock for me because in the UK it is very unusual for little children to be dying, especially at that rate. The difficult part is when you are the only one around and the nurses come to get you because the child has stopped breathing. There are no ventilators there and there is only so long that you can keep bagging & masking them. It is very difficult try to resuscitate small children with their mothers standing over you especially when you know that there is very little that you can do.

That was the hardest thing about this elective. The sheer numbers of children dying and you completely helpless is horrific. All you can do is only stand and watch them die right there, 10 centimetres away from you –knowing all the while that if they were in a western hospital the majority would live.
I learnt that it is a lie that it gets any easier, the more kids you see die, the more frustrating it is.

There were amazing positive points and experiences that I will never forget. One night at around 3am I was called to see a 6-year-old girl who had a severe asthma attack. The western drugs and delivery systems used for asthma are too expensive for most of Africa so they are not available. The standard treatment is adrenaline injections and aminophylline infusion. This girl was severely ill and was not getting any better on those. I had some salbutamol inhalers (I have asthma myself) and so went home and made a spacer device out of a large plastic bottle and got her to breathe through that with the inhaler on. She got better relatively quickly and that might have saved her life.

Experiences and situations like this teach us to use our heads and improvise when we don’t have everything that we might want available.

Death is looked upon very differently there. In the west people come to their doctor and expect to be cured. If they aren’t cured it is someone’s fault and it is considered a failure. In Africa death is part of life. When you die you become one of the ancestors.
People go to the hospital as a last resort – for many reasons, lots of them cultural but probably mainly because they cannot afford it. So generally when they arrive they are very ill, and the mentality of both the patient and the relatives is that they are either going to die or live.

The attitude to pain is very different as well. The pain threshold is either very much higher in the developing world, or here in the west we have no other worries so our pain is exaggerated to abnormal levels.
People there put up with pain as part of normal life. Childbirth is an amazing and beautiful experience in the developing world (in terms of labour and not all the relatively common complications that occur afterwards), when compared to the delivery suites on top of St. Mary’s. There is no screaming and swearing as if the world is about to end – it is still painful but it seems a more dignified way for a new life to begin.

It also seems that we in the west seem to be a little over sensitive with cleanliness. Everything is “single use only” and then thrown away. African hospitals cannot afford that so most things are bleached and kept as clean as possible. Even so all the wards and most of the hospital settings would be considered unsafe by our public health systems. This is mainly to do with the unavailability of clean running water but also with the hot climate where there is no air conditioning so windows need to be kept open. However the patients don’t seem to be getting more infections and are still recovering from their illnesses.
I believe there is a fine medium between African improvisation and western over-cleanliness.

Conclusion

My experiences both initial and then later on, were very unlike what I had expected. I was stunned by the standard of care that a man in this part of the world would receive during a hospital admission, and saddened by the impact in terms of debt or bereavement faced by the his family. In a traditional Kenyan farming family illness has far-reaching consequences, well beyond the emotional ties that link the family. I was amazed also to encounter such resignation and acceptance of both sickness and death –for a Kenyan mother, the untimely death of her baby is just one of those sad facts of a harsh life. I realised that my assumptions about patients, and the doctor-patient relationship I knew had no place in Kenya. My model of healthcare had to readjust itself to all these differences.

All of us, whether working in a teaching hospital in Manchester or a rural mission hospital in Africa, always struggle to do our best. It just so happens that our best, the best that we can do for the patient is different depending whether you are in Manchester of a developing country.
The standard of care is not any less in Africa – it is just different.

My experience in Africa was very fulfilling both on a personal and medical level. I experienced the very different lives of rural people in a less fortunate country and the difficulties they face throughout life. There are many different ways that we can care for our patients and the best way really depends on the patient and their circumstances and not the latest research paper.
There are many other different people and ways of doing things that are just as relevant. Many doctors would criticise the ways things are done in Africa but the most important lesson everyone needs to learn that is that all we can do is our best and that we are here to heal and not cure.

I plan to go back to Africa in the future to work ideally on a voluntary and humanitarian basis, and would truly recommend an elective in rural Africa for any doctor.

Elective Report – Luka Randic

  Placed   2008 & 2016 by   Žiža and Mirko