Wednesday, February 17, 2016

Challenges of Providing Neurological Care in Zambia, Part II

Challenges of Providing Neurological Care in Zambia, Part II  

In most Boston hospitals, medical emergencies come with a flurry of people in action:  A nurse or a resident placing a peripheral IV or a femoral line, monitors buzzing and beeping, pharmacists preparing medications as fast as they possibly can, and medications rapidly dripping through IV lines and into patients' veins.  At the University Teaching Hospital (“UTH”) in Lusaka, Zambia, the situation is very different. A patient in status epilepticus can go hours without receiving anti-epileptic drugs. Another patient with meningitis can go days without receiving a lumbar puncture (although, to be fair, there is significant taboo around lumbar punctures in Zambian society and Sub-Saharan Africa more broadly).  When we are reviewing mortalities during the daily morning report with residents and attending physicians, the clinical stories go something like this: “X-year old [gentleman/woman] with [heart failure/ stroke/ sepsis / disseminated TB/ fill in the blank] and no labs drawn [/ no medication given/ no imaging done] for X-days.” Physicians and nurses strive to give patients the best care and attention they possibly can, but making the “right” clinical decision for the patient does not always lead to a good outcome because of limitations in resources available. The pharmacy may be out of a medication, there may only be one dialysis spot available and 4 uremic patients to choose from, the CT scanner is down, or there simply may not be enough physician or nursing staffing bandwidth to attend to a patient’s needs. While there are many systemic causes for these problems in the Zambian health care system, the severe shortage of medical personnel has been especially very apparent to me during my time here.

With a population of 14.3 million, Zambia's patient community is enormous, yet the country has less than half the number of health-care workers required to adequately serve the population, including less than 2,000 doctors. As I mentioned in my previous post, there are three adult neurologists for the entire country. Without the development of new trainees, the neurological care in Zambia has been set up for failure. To combat this problem, Dr. Omar Siddiqi is hoping to establish the country’s first neurology residency and neurology fellowship program this coming fall.

One thing I have appreciated about my time at UTH has been taking part in different aspects of global health work. In addition to assisting with much-needed research and clinical care, I have also participated in expanding medical education and capacity building aimed at training effective practitioners. I have thoroughly enjoyed teaching medical students and junior residents, who have all been eager to learn and serve their patient population.

Some have argued that we can solve many medical problems in lower and middle-income countries (“LMICs”) like Zambia by simply purchasing the most modern technology and equipment for their hospitals. But, based on what I have witnessed at UTH so far, it’s clear to me that is not the only answer. The hospital staff must also be trained to properly use the equipment, and consistent and speedy technical support is needed to ensure the equipment is working at all times. For example, unlike some hospitals in LMICs, UTH has both a CT scanner and an MRI scanner. However, there is limited technical support, radiology support, and radiology technician support to properly and efficiently use these machines. When the CT scanner is not working, it can be down for weeks, because there is nobody locally able to fix the more complex problems that inevitably arise with the machine. Last week, a nurse walked into the MRI scanner with a metal oxygen tank, not having received MRI safety training. Furthermore, few radiologists at UTH have received formal training to read MRI studies.  Many of the MRI scans seem straightforward to me—but that is as a resident who reads MRIs on a daily basis.  Therefore, in addition to providing much-needed resources, like CT and MRI scanners, hospital staffs must also be trained properly so these additional resources can be used effectively.  I have seen the same sort of scenario unfold with regard to EEG machines. 

I am very grateful for having had the opportunity to come here this month, and to learn from Dr. Siddiqi and the physician staff at UTH. As I try to incorporate global health interests into my own career, I will surely also be incorporating the lessons I have learned here--particularly in terms of sustainability and providing adequate training.

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