Challenges of Providing Neurological Care in Zambia, Part I
It has been an eye-opening experience for me at the University Teaching Hospital (UTH) in Lusaka, Zambia, where I have been practicing as a neurologist this January, thanks to the MGH Center for Global Health Travel Grant. UTH is the largest hospital in Zambia with 1655 beds, a teaching hospital affiliated with the University of Zambia School of Medicine and a center for specialist referrals from across the entire country. I have been working with Dr. Omar Siddiqi from the Beth Israel Deaconess Medical Center. Dr. Siddiqi is one of three adult neurologists in the entire country (a population of 14.3 million people), and is working on enhancing TB meningitis diagnostics as well as building Zambia’s first neurology residency program. In Zambia, my workdays are strikingly similar to life as a medical resident in Boston: I see inpatient consultations, outpatients, and teach medical students.
But, there are many differences as well. For example, grieving is a very public process in Zambia. The hardest aspect of my job has been hearing the heart wrenching wailing and sobbing of patients’ family members reverberate throughout the hospital corridors, as they struggle to cope with the death of a loved one. Although painful to hear, I also remind myself of the silver lining in their grieving voices: many of the patients at UTH are surrounded by the heartwarming presence of their families and communities during their final days. This is a strength that I have found often exists in resource-limited settings such as Zambia. Because of the high patient to nurse ratio that cannot accommodate the entire patient population at UTH, many patients have family members take turns as their primary caregiver in the hospital (“bedsiders”). These family members perform many tasks traditionally performed by nurses in the United States: from bathing to feeding to even taking serology tubes to the laboratory.
Clinically, Zambia carries one of the largest HIV and TB burdens in the world, and the burden of CNS infectious diseases as a result of these infections is significant. Within the last two weeks, I have seen cases of cryptococcal meningitis, TB meningitis, Pott’s disease (TB in the spine), cerebellar atrophy from primary HIV infection (among many others). An equal caseload in the United States would take years to see and diagnose. I have been impressed by how fluent the residents and attending physicians at UTH are in the language of infectious diseases. I had to provide myself a crash course in neuro-infectious diseases just to keep up with the medical staff. These cases are certainly not the “bread and butter” of neurology that I have seen in Boston throughout most of my residency.
But, just as infectious diseases disproportionately impact low and middle-income countries (LMICs) like Zambia, so do non-communicable diseases (NCDs) such as stroke. In fact, nearly three-quarters of NCD deaths worldwide occur in LMICs. At UTH, I have also seen a significant number of NCD cases. While awareness of infectious diseases has increased in recent years, education about NCDs such as stroke is still low in Zambia. For example, a cab driver told me: “My friends and I are more worried about having a stroke than HIV, because we know there is treatment for HIV.” Stroke, he said, is considered to be more of an unknown disease. Furthermore, a patient asked me in clinic if there was a medicine I could prescribe to him to return strength to his muscles after a stroke. And, another patient’s daughter was brought to tears when I told her that the damage to her mother’s brain was permanent. She was unaware of the irreversibility of damage from chronic diseases such as high blood pressure, high cholesterol, or stroke. These experiences demonstrate to me that educational and clinical efforts in global health must expand beyond infectious diseases and must include NCDs.
Despite these challenges, I have admired the Americans like Dr. Siddiqi who have brought their entire lives here to study infectious diseases and help strengthen the local medical infrastructure, just as much as I have admired the devoted Zambian doctors who work grueling hours with a significant patient work load. I am also thankful for the travel grant and eager to continue learning for the remainder of my time here.