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.
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