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.
This is so inspiring! Amazing work. I'm sure many others will be inspired to take on this path as well.
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