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.