Medicine, Juba-style

I only have one week left here in Juba, I'm not quite sure how that crept up on me, but it has. I haven't written much recently, not because nothing has happened, but because I haven't known what to say about it. As I near the end of my time here, I get asked about my feelings about leaving; there are lots of thoughts that come into my head, but I know that I'm ready to leave. It's going to take a while for me to work out what I've achieved, learnt, experienced and given here; I think it's too early to start making those conclusions - I'm going to need a bit of thinking time for that.

Over the last few weeks, I've been trying to go to the government hospital and get involved where I can. It has been a bit of a struggle though, the more I go, the more emotionally and mentally draining I find it. On ward rounds, I frequently end up having in depth discussions with the consultants or other doctors about the approach that is being taken towards a particular problem. It has been pretty difficult to know when to say something and when not to. As I've probably said before, I'm determined not to be the western guy who comes along and tells people that because they are doing things differently, they must be wrong. That can't be the way to improve things - it doesn't help relationships with staff, and if you don't have a relationship they aren't going to take an interest in anything you do or say. However, the real dilemma comes when they are doing something wrong - what do I do then?

I probably need to expand on this. There are lots of reasons that people get different investigations or treatments here in South Sudan. Firstly, it could just be that treatments or investigations are unavailable or too expensive; this isn't exclusively referring to getting an MRI scan or serum rhubarb measurement, many people can't afford the most basic drugs and are at the mercy of the erratic and unpredictable supply of free drugs from the hospital pharmacy. So sometimes really odd drugs are prescribed because they are available for free, and they probably will work. Sometimes drugs will be given that are just plain bizarre; aside from multivitamins that are used for a plethora of random indications, drugs that I've never heard of such as piracetam (for myoclonic jerks) will be used to "improve memory" in stroke patients, without any evidence of memory problems (also, piracetam is contra-indicated in haemorrhagic stroke, and until recently no-one was getting a CT). In fact a stroke patient is much more likely to get piracetam than aspirin and a statin (the most basic medications that have evidence showing they help if people have had a stroke). Sometimes older investigations and treatments are used as they are cheaper or the only thing available.

This all leads to multiple occasions where I don't know if the other doctor is coming up with medical brilliance in the face of adversity, or if they've just made something up. I may have mentioned before, that the doctors do care, and want to do something to help the patient, even if nothing that is really helpful is available, but sometimes they end up possibly causing more harm than good. If a consultant prescribes an incorrect drug then the juniors all take it as law that you must do that when faced with this sitiation, without ever thinking about what is actually happening. I get mentally exhausted trying to work out if what has been said is true or not throughout the entire ward round, and emotionally exhausted when trying to work out when I should argue my case or when I should stay quiet. This is without thinking about all the patients who the healthcare system here cannot help. with or without multivitamins.

It's a shame, because one of the challenges of doing medicine here that I find most rewarding  is trying to do the best with what you have available, whether that be in diagnosis or treatment. A lot of the time you have to be a bit creative with the treatment, working from first principles of a disease, rather than just knowing that you give drug x in a certain situation. Often you have to make you 'best guess' of the diagnosis from the examination of the patient and minimal investigations. There is no safety net of investigations for precise confirmation of diagnosis. Wherever you work, medicine involves a degree of uncertainty, but here things are much less certain than elsewhere.

Thoughts of a Coffee Drinker

Powdered milk makes tea taste of cheese, which somewhat limits the enjoyment of drinking it. However, it is possible to get decent coffee in Juba. I was going to conduct a rigorous scientific survey to identify the best coffee here, but it turns out that there is so much variation within each establishment that I couldn't afford enough coffee in order to have a large enough sample size. I have tried though.

While sat in a very pleasant cafe the other day, for coffee research purposes, I had a bit of time to reflect on my last few weeks and to take in my surroundings. The week or so following my last post was incredibly frustrating, I think a lot of little things about working here got to me. I was very frustrated with the system, and many of my colleagues who didn't seem to care about patients or improving the systems they work within. I got to the point that I was dreading going in to work. I don't know if I was fed up of telling people we couldn't do anything for their illness, or if doing the ward round and finding that my colleagues hadn't done anything for any of the patients since I last saw them.

I have realised that there are huge cultural differences between myself and the local doctors, partly stemming from the fact that they have to make do with what they have here; I get frustrated when I see people prescribing completely random medications for people (ranging from the ubiquitous multivitamins to anti-hepatitis B drugs in people with any kind of liver problem), they are just trying to do something for the patient. As medicine here improves (and it is, if you have money at least) the old attitudes are hard to let go of, and evidence-based medicine is having a tough fight to break through. I imagine if I had always worked in a limited-resource setting such as this, I wouldn't be so emotionally involved with my patients, as there are so many of them that you can't do anything for. Even if you can't cure someone back home, there are almost always things you can do to help their symptoms and to ensure their emotional wellbeing.

Part-way through my second pot of coffee, I realised that I had almost written up a report on an audit that I started last week. I found myself looking forward to my shift at work, and my trips over to the government hospital. Some of the things they do still drive me completely mad, but I think I've learnt some tolerance and understanding about what makes my colleagues tick. I was determined that I wasn't going to be the guy who came out and told everyone that they're doing it wrong; it's a tricky balance to strike, because people do ask how we would do something in the UK, but I need to remember where I am and the limited resources that we have here. I think my week or so of giving up is over, but with less than 3 weeks left here, I have a lot still left to do.

Getting Blood From a Stone

Last night, I discovered that getting blood from the government hospital might be more of a challenge. I apologise, this post is quite medical, but so is my life here. I want to tell you about a patient who I have been looking after and some of the challenges which we face here, as well as my feelings and reflections on it. I'll try and write in normal language, but will put some geeky medical details in for those that care.

Two nights ago, I admitted a patient who had been suffering from bloody diarrhoea for nearly a week. Over that time, he had lost a significant amount of blood (his Hb had gone from 10 to 4 g/dL in 4 days) and had become quite unwell. He was severely dehydrated, as well as suffering the symptoms of anaemia - breathlessness, lethargy, and just generally being quite unwell. I did all the simple things and requested some blood to transfuse; this has to be collected from the government hospital blood bank in return for donations from friends/relatives to replenish stocks. After about 4 hours, a single unit of blood appeared for transfusion, with the news that no more was available until the following day. The patient was stable, so I let the doctor on the night shift know all about him and finished my shift.

Last night I was on the night shift, and very early on I was called to the ward to see this same patient. If you're particularly sensitive/squeamish, you just need to know that things had happened which meant that he needed more blood, and I'd probably skip the rest of this paragraph. I found the patient face down on the floor in a metre-long pool of blood and clots, which he'd just deposited as a bowel motion. He was still just about conscious (and somehow had a reasonable BP, but was very shut down).

I'd discovered that on top of this new issue, nothing had really been done for him all day, and even when I arrived, there was no particular hurry to do anything. I decided that wasn't really good enough, so surprised the ward staff by running round the ward finding cannulae and fluids and administering them within a couple of minutes (usually a fluid challenge will take about 30 mins to be given, unless you do it yourself). Without any clever plans to stop the bleeding until the morning, all I could do was give him more blood to replace the losses. After the previous night's issues, I decided to go to the bloodbank myself with 7 donors to request the blood that the patient needed. After a lot of discussion with the staff there and about 1 hour, I returned with 1 unit of blood, having been told that I wouldn't be able to get any more until the morning, despite all my best arguements.

Making the most of what we had, I made a plan for overnight and he recieved the blood and fluid. Thankfully, he was a little bit better by the morning, and I managed to get a second unit of blood for him in the morning (it did take another 2 hours though). The doctor who is currently in charge here took over from me in the morning, and we discussed a plan for the day to ensure he had more blood and was reviewed by someone who could possibly investigate the source of the bleeding. I went to see him this evening, and although he's still stable, nothing has been done for him all day.

Last night was one of the very few occasions where I've become outwardly frustrated/angry in a medical setting. It happens very rarely, when I feel that patients aren't receiving the care that they need for no good reason. I'm not proud that I got angry, it never helps anything happen any quicker, and I think sometimes it might even make people more obstructive, thankfully it didn't last long and the calm me got a lot more done than the angry me. Having slept and thought about it, some of the problems last night were not solveable, but some really were.

In the blood bank, there were many other samples waiting to be matched for units of blood for transfusion for patients who had been shot, had fallen off their motorbikes, had just given birth, and had severe malaria. The 'blood bank' is in fact a fridge, which is barely larger than the one in your kitchen, and serves the whole of the city. If I'd got all the blood I'd wanted last night, it's quite possible that I would have exhausted their stocks of that blood type. So I probably was a bit unrealistic and demanding to expect to get so much blood last night, given the limited-resource setting that I've found myself in, remembering that my patient probably wasn't even the most unwell patient in town.

However, the apparent lack of interest from my colleagues, and the constant excuses of why things can't be done (I had to convince the nurse that the electricity going off in 3 hours was not a reason not to give a blood transfusion, and that the pool of blood which had recently formed on the floor was a very good reason why we should give it now). Maybe I'm too emotional, but I get a bit upset when people don't seem to care. It isn't a problem I have to deal with too much at home, but I don't know how to change the attitudes of a whole hospital (or so it seems). If anyone has any bright ideas, there are many people here who would love you rather a lot.

Anyway, that's enough for today. Sorry it was a bit of a medical rant, I promise my next post will be about my hunt for the best coffee in Juba or something like that.

Normality

Something starnge has happened over the last few weeks, I can't put my finger on a particular day or moment, but something has changed. Being in Juba has become normal. I no longer feel like being here is a novelty or completely foreign to me - I have adapted my way of life to how things are here, and it feels like I was never anywhere else. Don't get me wrong, there are many things that I miss - friends & family, white tea that doesn't taste of cheese, climbing, feeling cold, the sea, and good beer to name a few - but in the same way that I miss the snow in summer and the sun in winter, it's just normal.

I think part of this is that I have developed a routine; I find this odd because I always thought I thrived on chaos, but over the last few years I realised routine is good for me. It isn't strict routine, it never can be when I work every fifth night and random shifts, but there is definitely a routine. I don't know if it just helps me know what day of the week it is, or if it's the fact my routine often includes 'normal' things like going for runs, meeting friends, and going to church. It could be that I just know what is coming over the next few days, so life isn't quite such a mystery.

I spend time with people who have been working here for much longer than I have, and they all speak of life here as if it is normal. Obviously some of the things that we discuss as normal would be completely alien back in the UK, like not being able to reach other towns in the rainy season (or people not coming to work because it's raining - imagine if that happened back home!). Just having a social network of sorts makes life more normal too.

Having 'normality' means that I'm just trying to get on with all the various projects which I've found myself involved in: work, teaching, audits, service improvement, and learning medicine. That's pretty good, as I only have just over a month left here, and still have a lot to do (in a couple of areas I've probably bitten off more than I can chew). I doubt that I'll finish everything that I've started but that's probably a lesson in itself - discovering how long things take to achieve and quite how hard you have to push to get things done here; it can be pretty time-consuming, but overall, very satisfying.

Differences

Everyone is different. That's a pretty exciting thing about life; some differences are pretty big and some are tiny and virtually inconsequential. There are a few differences that I thought I'd mention today, for no particular reason, other than they happen to be rumbling round my head.

I had a long conversation with a patient today about his treatment for diabetes. He was rather frustrated, and was requesting that I refer him to a more advanced hospital in a neighbouring country because, after a whole month of medication, we hadn't cured him. I don't know how things were explained to him a month ago when he was diagnosed, but somewhere along the line, the concept of a chronic disease has been lost. Back in the UK, most of the patients I see have at least one ongoing disease, which is highly unlikely to ever be cured; I spend a significant amount of time dealing with complications of treatment for chronic conditions. Here, things are different; far fewer people are diagnosed with chronic diseases (I'm not sure why, maybe because they have a better lifestyle, maybe because the life expectancy is less due to acute illness - it's probably too complex a question for me to answer) and several times over the last month or so, I've had patients who are very suprised that their diabetes or epilepsy hasn't been cured after the first month of medication. Like many problems in healthcare, good communication can go a long way; explaining that even if I referred my patient to the best hospital in the world, he still wouldn't have his diabetes cured and that all we can do is control it the best we can with daily medication and try and avoid the complications. I'm sure as things continue to change in South Sudan that this and many other differences may be addressed by doctors and patients alike.

That example was of a difference, which is more towards the negative end of the spectrum. Lots of differences are much more positive, and lots are just different. Everywhere you look at lunchtime, people are eating together and chatting - often if I'm out running in the evening, the pavement is blocked by groups of men sitting round and drinking tea. There seems to be, in some respects, more of a community than there is back home.

Some differences are completely trivial, but for some reason happen to stick with you. Almost without fail, whenever I ask a patient to lie on the examination bed in clinic they put their hands behind their head - I'm sure people don't naturally do this in the UK. It doesn't matter at all, I just find it odd that everyone does it. I imagine they find it odd that I drink my tea black and without sugar (powdered milk makes it taste of cheese) when the average is about 4 sugars in each cup.

All in all, differences are what make going new places and meeting new people so interesting - it lets you see that there isn't just one way to think about something or do something. We all have a lot to learn from our differences. Who knows, maybe I'll start expecting diabetes to be cured, I know for sure I won't have sugar in my tea though...

It's Not All Work

I've realised that all of my posts so far have been serious and have just been about work and some of the problems that I've found while out here. Although that's the reason I'm here, it isn't all that I do. I've been really luck to get involved with various social things and have found ways to keep myself occupied in between my shifts.

When I arrived here, I knew nobody. Through a series of very random meetings, I have now made quite a few friends and found some leisure activities. Juba is a funny place, there are hundreds of NGOs based here, and the local economy has adapted to cater for their needs. There are several bars and restaurants which cater mainly for the desires of foreign workers; interestingly, since the last time I was here, you see a lot more South Sudanese locals also frequenting these places. It is a sure sign that at least part of the population is becoming more affluent.

There are often stark contrasts when visiting these places, next to some of the riverside restuarant/bar/hotel places is a graveyard, which is a little sobering; however it isn't a graveyard like the typical ones you see back home - between the gravestones are lots of small huts, where people live in complete poverty. Across Juba, this contrast is evident; new, large houses surrounded by tiny straw shacks. Currently it seems like there's quite a class divide.

Apart from going out for drinks and dinner, there's lots more to do. Those of you who know me will know that I like to be quite active, and although I haven't been that good for the last month, I'm starting to get out and do some exercise. If you know where to look there's quite a lot to do - I've started playing Ultimate Frisbee, which isn't technically a sport, as a dog can play it, but it is a good excuse to run around for an hour and make some new friends. The locals who walk past while we play look a bit amused, that might be because they haven't really seen people playing frisbee, or it could be because they can't imagine a situation where they would need to do more exercise or have time to. I certainly get some quizzical looks when I go out running too.

Of course, theres also my main sporting love, which is climbing. There are some exciting looking boulders dotted around the city, which would be amazing if they were more than a metre tall. Outside the city there is a 'mountain' which has some rocky bits, but I haven't made it there yet. Rumour has it that someone has bolted some routes there, but I only have my shoes, so I'll stick to the boulders. While I wait for an opportunity to get out on some rock, I've found a way to keep my fingers strong. When making my room, someone very kindly added a small (1.5cm) foot ledge around the bottom; combined with the corners and doorways, some fairly testing bouldering problems can be found. I think I have a problem, and it's not going away any time soon. I can live with that.

Healthcare's Dark Secrets

Before I came here, I knew I was going to come across problems that I hadn't seen while working in the UK. Some of them were pretty obvious, such as having to work with limited resources. It doesn't make it any less challenging, especially when you have to tell patients that they have a serious illness, but we can't treat it; telling someone they need to go to Egypt for chemotherapy, or even a CT scan, never gets easier or less surreal. Some of the problems I face are a bit more of a surprise to me, and they make me a bit angry sometimes.

I thought that I may see patients who had not come to see a doctor earlier because they had tried traditional remedies first, and although I see occasional signs of traditional medicine, it doesn't seem to be the major reason for patients presenting late in Juba. To set the scene, I should probably explain the health system here. Healthcare is provided in Juba by a huge number of private clinics; some of them are large, clean(ish) medical complexes; most of them are dirty, small and completely under-resourced. They are all for-profit, as far as I can tell. From my experience at one of the better clinics (the hospital where I work most of the time) and the government-run hospital, it seems that most patients will visit one of the smaller clinics first if they become ill and if the don't get better will either try a more expensive one (if they have money) or go to the government hospital (if their money has run out). In theory, this model isn't the worst, at least there is healthcare provision, but I have found that there is a darker side to many of these clinics.

What I'm about to say is all based on my personal experience and the views of people that I have met, but I have found no evidence that it isn't true, and plenty that it is. Many of these small clinics are staffed by people with minimal training, and without trained medical staff to consult with, following inaccurate algorithms according to what the patient presents with. Although this isn't ideal, you can understand it happening when there aren't enough doctors to go round. Sadly this isn't the main problem - many of the patients who are seen in the clinics are diagnosed with "Malaria and Typhoid", and given treatment which may or may not be effective for the condition they actually have (which may really be malaria and/or typhoid). The basis of these diagnoses is laboratory testing, which is often hugely flawed and often not even done at all. Yesterday I had a patient who had "malaria and typhoid" and had his notes from the clinic he had visited (a rarity in itself) - he showed me his results 'proving' the diagnosis, which consisted of a negative malaria test and an estimation of his white blood cell count (which isn't even the hugely flawed test for typhoid that everyone uses here - it's just a non-specific marker of infection and inflammation). He'd been prescribed various injections, but none of them were appropriate for his actual problem of indigestion, which is why he found himself visiting me, after not getting better. This is not an isolated case either.

Sometimes it is even worse, with patients being admitted to private clinics and paying lots for expensive tests (which may not even be performed) in more complex cases until their money runs out, when they are discharged and told they don't know what is wrong and that they need to go to the government hospital instead, or ideally to Egypt or Uganda (which is hugely expensive).To make matters worse, even if patients are correctly diagnosed, and prescribed an appropriate medication, the actual medicine they buy might not actually be genuine. I read recently that over 35% of antimalarial drugs tested in Sub-Saharan Africa are counterfeit, which at best means that the patient recieves a placebo, but could mean that they get a sub-therapeutic dose of the medicine (a highly effective way to cause resistance to one of the only effective medications we have) or even something highly toxic. False drugs are a global health problem, and hit the poorest people hardest (as the false drugs are cheaper than genuine ones).

All of this makes me a pretty angry, as there are people who are clearly putting money ahead of people's lives and wellbeing. I don't know how far this spreads and who makes the money out of these clinics and false medicine. If it is local people here, fighting to make a living, then maybe you can see why they think it is ok to do this (it still definitely isn't ok at all) and maybe a solution can be found by providing other ways for them to survive which don't but people's lives at risk. If it isn't people fighting on the poverty line, then I just don't get it - how do people justify making a profit from harming other human beings? I don't think this is a problem limited to Juba, but it's never talked about and having seen the effects of it for myself, I thought other people might like to know.