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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