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.
Tuesday, 30 April 2013
Tuesday, 23 April 2013
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.
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.
Sunday, 14 April 2013
Some Things Never Change.
Over the last week, I've started going across to the teaching hospital (where I was as a medical student 5 years ago) on ward rounds with one of the consultants who also works at the hospital where I work. Having seen the huge changes elsewhere in Juba, I was intrigued to see what had happened to the hospital since I was last there.
On my few visits so far, it seems the last 5 years haven't been so kind to the hospital. When I was last there, basic medications were available for patients free of charge, and there was an air of optimism around the hospital. Now there are no drugs or fluids, and often limited electricity. There are hard-working doctors and nurses, but they have very limited resources. Patients have to go and buy any medicines that they need, and apparently they often need to buy their own cannula and the gloves for the staff who are inserting it - which adds even more pressure if its a difficult cannula.
It's strange to see all the change in Juba without a corresponding improvement in government healthcare. I'm sure there are lots of reasons why, although I think part of it is that there has been lots of private investment, without much government investment. It will be interesting to see if anything changes, as the ongoing problems between north and south over oil revenues seems to be less problematic than it has been, so hopefully the country should get some money.
My work at the private hospital is going quite well, although it's often not very busy, which means that shifts can drag a little bit. The rounds at the teaching hospital are a huge contrast from the private one - there are lots of patients in the teaching hospital who have presented late (for various reasons) and who are very unwell. The prevalence of TB is huge, and it presents in a huge variety of ways. Thankfully, basic TB and HIV (which is also quite common, when people are actually tested) is free thanks to the WHO, among others.
Apart from all the tropical conditions, which are rare in the UK, we also have our share of patients who have more "common" conditions such as strokes and heart failure. We currently have 3 patients who have had strokes, all of whom have a very different future compared to similar patients in the UK. Here we don't have stroke units with intensive physio and OT input, specialist nursing and doctors who walk around looking important. There are some pyshiotherapists around, but they seem pretty stretched, if they are at the government hospital, and expensive if they're private. Even after the acute "rehabilitation" they receive in hospital, there are no government funded carers or specialist equipment; their families have to look after them without any formal outside help. Compared to many other places, disability doesn't have as much stigma attached to it, and family groups are often close-knit; but on a practical basis, having someone who isn't able to earn money or run the home, who needs to be supported, is going to make it pretty tough for a family who is probably only just managing as it is.
On my few visits so far, it seems the last 5 years haven't been so kind to the hospital. When I was last there, basic medications were available for patients free of charge, and there was an air of optimism around the hospital. Now there are no drugs or fluids, and often limited electricity. There are hard-working doctors and nurses, but they have very limited resources. Patients have to go and buy any medicines that they need, and apparently they often need to buy their own cannula and the gloves for the staff who are inserting it - which adds even more pressure if its a difficult cannula.
It's strange to see all the change in Juba without a corresponding improvement in government healthcare. I'm sure there are lots of reasons why, although I think part of it is that there has been lots of private investment, without much government investment. It will be interesting to see if anything changes, as the ongoing problems between north and south over oil revenues seems to be less problematic than it has been, so hopefully the country should get some money.
My work at the private hospital is going quite well, although it's often not very busy, which means that shifts can drag a little bit. The rounds at the teaching hospital are a huge contrast from the private one - there are lots of patients in the teaching hospital who have presented late (for various reasons) and who are very unwell. The prevalence of TB is huge, and it presents in a huge variety of ways. Thankfully, basic TB and HIV (which is also quite common, when people are actually tested) is free thanks to the WHO, among others.
Apart from all the tropical conditions, which are rare in the UK, we also have our share of patients who have more "common" conditions such as strokes and heart failure. We currently have 3 patients who have had strokes, all of whom have a very different future compared to similar patients in the UK. Here we don't have stroke units with intensive physio and OT input, specialist nursing and doctors who walk around looking important. There are some pyshiotherapists around, but they seem pretty stretched, if they are at the government hospital, and expensive if they're private. Even after the acute "rehabilitation" they receive in hospital, there are no government funded carers or specialist equipment; their families have to look after them without any formal outside help. Compared to many other places, disability doesn't have as much stigma attached to it, and family groups are often close-knit; but on a practical basis, having someone who isn't able to earn money or run the home, who needs to be supported, is going to make it pretty tough for a family who is probably only just managing as it is.
Saturday, 6 April 2013
Motivations
As I get properly into the swing of things, I’m trying to
work out what I’m meant to be doing here and why I’m doing it. If by late June,
when I plan to leave, I have just gained experience of tropical medicine in a limited
resource setting, will I feel satisfied? Or will I think that there was much
more that I should have done? Currently I’m just doing “service provision”
without any attempt at “service improvement”, which could be much more
productive in the long term. I’m experimenting with ideas for teaching and for
audit, but it’s difficult to know what is actually useful in the long term. I
could gather data and do an audit on anything, but how do I know it will
actually be any use? I think a bit of patience, and waiting for a problem to
become apparent – either from experience, or from talking to the staff here. As
for the teaching, I don’t want to be the western doctor who comes over, tells
everyone they’re doing it wrong and then disappears again. I want to set up a
system of mutual development, which will continue when I leave – this might be
a little romantic, but at least I’m setting out with good intentions.
Intentions and motivation are an interesting point, which I’ve
been thinking about a bit over the last few days. My reasons for being here are
many, and vary quite widely. Some are at the more self-centred end of the
spectrum; I want new experiences, to maybe make me a broader, more interesting
individual and to help me understand myself more. I would also be lying if I
said that this trip, and doing audits and teaching wouldn’t be helpful for
ticking boxes and career progression in the future. As long as I’m honest about
these, I don’t think they’re particularly bad reasons to be here, but they’re
not my only reasons. I’ve known for quite a while that I should come back here
and be more helpful/productive than I was when I was a student (not really that
hard), and I do really care about South Sudan and its people; I think I’m meant
to use the skills I’ve been given to do something productive here, even if I’m
not quite sure what the big plan is. As for future big plans, they’re quite
hazy still – several friends that I’ve met that are working with NGOs out here
have asked about future plans, and right now, I really don’t know the answer.
On a broader level, it’s been interesting to find out about
the motivations of the other doctors that I work with – it has definitely been
challenging. One of the doctors that I work with also works at the government
hospital, and at another private clinic. He’s easily doing the equivalent of 2
full-time jobs. When I spoke to him about why he works so much, he explained
that he supports his mother and brothers, who are in Sudan and Uganda, to
ensure they have enough to live on and study. I didn’t ask for a copy of his
accounts, but from what I know, at least two-thirds of his ‘disposable’ income
goes to his family. That made me realise just how fortunate I am. My motivation
for doing medicine is not money; that said I’m incredibly fortunate that I get
paid well for doing a job that I love. I’ve realised how lucky I am that this
can be the case, my family haven’t been displaced by decades of conflict, and
they live in a country that has a pretty good state welfare and education
system (sorry daily mail readers, but it’s true in comparison to a lot of the
world); when someone gets sick there isn’t the need to spend all my money on
private healthcare for them, because we have a health system that provides
excellent care. I’ve got a bit of a new perspective on life; I wonder how (if
at all) it will change me?
Tuesday, 2 April 2013
One week in...
The last week or so since I arrived has been a pretty interesting time, I've
had to find my feet in a new hospital, new city, new country (new to me and new
to itself) and new culture. Although I've been here before, I've realised it's
very different when you're by yourself, especially when you're not naturally
that assertive or confident. Thankfully, I have settled in and have got to know
the hospital, some of the staff, and have even made some friends from outside
the hospital. Every day I think of something that I could write about on here,
but no-one wants to read what I think that much, so I think I will just pick up
a couple of thoughts that I think are particularly interesting, and help me to
give a picture of things that happen while I'm out here.
While I was planning this trip, one of my main aims was to improve my clinical medicine (to any non-medics reading this, clinical medicine is using what the patient tells you and what you find on examining them, rather than test results), because it isn't as easy to run a whole barrage of tests like we do in the UK. However, I am learning that it is not going to be straight forward.
When I am working, I spend most of my time in the clinic, which is where all the patients initially present to the hospital - if the are really sick, we admit them, if they are a little bit sick we give them treatment and send them home. Common presentations in clinic are fever, vague abdominal pains, headache, diarrhoea, and a myriad of rather weird complaints. A lot of the histories are quite vague, which I struggle with; I like to spend a while working out exactly what the pain is like, and the complete sequence of events. I was thinking about why this might be and realised it's probably a mixture of a 3 main things. Firstly, there are a number of language barriers; most of my patients speak english, but sometimes I need someone to interpret as the patient speaks arabic or one of the many tribal languages. This is definitely less effective than me talking to another native english speaker. Secondly, a lot of the conditions that I see present quite vaguely anyway - the main one is malaria, which can have a huge range of symptoms - fever, headaches, diarrhoea, coma, heart failure. The final reason is to do with patient education; even though a lot of my patients are from the South Sudanese middle class, the rate of secondary education is pretty low. Often the descriptions of symptoms are pretty bizarre, or inaccurate - several people complaining of complete leg weakness even though they can walk normally. It is interesting to compare this to patients back home who are often very well informed on their condition, although this often isn't a good thing - there are lots more websites telling you that your headache is a brain tumour rather than the classic migraine that you're having.
I'm slowly getting to grips with the subtle nuances of history taking here, but the standard approach from the doctors here is to take a quick history and then run off an array of tests, almost blindly checking for malaria, amoeba and other infections. So I'm not sure that I'm going to be a diagnositic genius by the end of my time here, but I should get better at assessing sick patients. A lot of the tests that I would do on a very sick patient (O2 sats, blood gases, cultures, regular monitoring) aren't available here, so I have to trust my clinical skills and frequently re-examine patients to see if they are improving or if I need to do something else. This should be useful when I'm back in the UK as tests take time, and often making decisions on what to do next is based almost entirely on clinical judgement.
That's probably enough for now.
While I was planning this trip, one of my main aims was to improve my clinical medicine (to any non-medics reading this, clinical medicine is using what the patient tells you and what you find on examining them, rather than test results), because it isn't as easy to run a whole barrage of tests like we do in the UK. However, I am learning that it is not going to be straight forward.
When I am working, I spend most of my time in the clinic, which is where all the patients initially present to the hospital - if the are really sick, we admit them, if they are a little bit sick we give them treatment and send them home. Common presentations in clinic are fever, vague abdominal pains, headache, diarrhoea, and a myriad of rather weird complaints. A lot of the histories are quite vague, which I struggle with; I like to spend a while working out exactly what the pain is like, and the complete sequence of events. I was thinking about why this might be and realised it's probably a mixture of a 3 main things. Firstly, there are a number of language barriers; most of my patients speak english, but sometimes I need someone to interpret as the patient speaks arabic or one of the many tribal languages. This is definitely less effective than me talking to another native english speaker. Secondly, a lot of the conditions that I see present quite vaguely anyway - the main one is malaria, which can have a huge range of symptoms - fever, headaches, diarrhoea, coma, heart failure. The final reason is to do with patient education; even though a lot of my patients are from the South Sudanese middle class, the rate of secondary education is pretty low. Often the descriptions of symptoms are pretty bizarre, or inaccurate - several people complaining of complete leg weakness even though they can walk normally. It is interesting to compare this to patients back home who are often very well informed on their condition, although this often isn't a good thing - there are lots more websites telling you that your headache is a brain tumour rather than the classic migraine that you're having.
I'm slowly getting to grips with the subtle nuances of history taking here, but the standard approach from the doctors here is to take a quick history and then run off an array of tests, almost blindly checking for malaria, amoeba and other infections. So I'm not sure that I'm going to be a diagnositic genius by the end of my time here, but I should get better at assessing sick patients. A lot of the tests that I would do on a very sick patient (O2 sats, blood gases, cultures, regular monitoring) aren't available here, so I have to trust my clinical skills and frequently re-examine patients to see if they are improving or if I need to do something else. This should be useful when I'm back in the UK as tests take time, and often making decisions on what to do next is based almost entirely on clinical judgement.
That's probably enough for now.
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