Dr Reina Ramesh shares her experience as a doctor in rural west africa that is both
enlightening and entertaintaining..
As a primary health care physician in a rural setting in Nigeria working with one general practitioner and ten Nigerian nurses/technician staff in a 300 bed hospital we provided comprehensive health services to a large African population. The extent of those services was limited both by the finiteness of our own skills and Hospital Queue
those of our African staff and, importantly, by the distance between our isolated site and the capital city and with often impassable dirt road that linked us with the closest major urban centre. My exposure to these hospitals, to hundreds of patients who had known health care only by a village healer or at a government centre, together with visits to several National Health Service hospitals, provided an opportunity to compare the organization and content of African with Western medical care programs, an opportunity at once instructive and humbling.
By Western standards Nigeria is a poor country. By African standards it is relatively prosperous, enjoying the natural resources and productivity of dense forest belts, rivers and variably fertile savannah soils. However it is intent on developing its industrial and cash crop potential, with small commitment to rural health care programs. This little town in Nigeria had river water made safely potable, had indoor plumbing and an always erratic supply of electric power. In this 300 bed hospital, the physician works six full days and is on call every Sunday. He has full responsibility for all medical and surgical care. His annual vacation leaves the hospital without a replacement. In his absence the nurses provide services whose scope is defined by their courage to respond to patient needs.
Although the belief is still widely held that medical practice in tropical Africa consists largely of treating exotic parasitic diseases, in reality it encompasses the full range of human illness. There are some significant difference in experience with diseases between rural Africa and a western population – the Africans often have a marginal nutritional status, they lack the amenities of sanitation that protect efficiently against infections borne by food, water and soil; they retain a strong faith in the healing powers of both native Shamans and indigenous medications, a belief that often entails delays in seeking more modern health care when that is available, and that too they have little, if any, experience with preventive care.
Although most westerners have little knowledge of Schistosomiasis, Onchocerciasis, Leprosy and a host of other diseases endemic to tropical regions, Africans are not less familiar with Tuberculosis, Asthma, Measles, Venereal diseases or Hypertension. Because modern health care is unknown to most rural Africans, itis not unusual to find adult men and women who have never seen a thermometer, nor had a stetescope applied to the chest. Physicians are scarce, widely scattered among few cities and absent in the villages of the forest and savannah. A system of health care stations run by nurses or nurse-midwives is sparsely dispersed. At these clinics government doctors make erratic visits. Ambulances are few, in unreliable repair and often too distant from a medical centre to be useful.
Rural African hospitals are found only in a few larger communities, not easily accessible to large number who must walk, make use of the bush taxi system or be carried if they live far from the few roads serviced by these vehicles. Striking some balance between them and our western counterparts are the Christian mission hospitals, where physicians have been recruited from western countries. They work with hand-me-down equipment and unreliable lines of supply. The most notable outward contrast with western hospitals is an apparent indifference to sanitation.
The westerners compulsion to cleanliness may be compulsive, but grossly dirty floors and walls that welcome cockroaches and lizards, torn, soiled mattress often without linen, and the occasional multiple occupancy of beds in government hospitals are scarcely compatible with modest standards of hygiene. Add visiting families sitting, eating and sleeping on the floor, children, remarkably well behaved but at times depositing their excrement on the bed or floor and the total picture of septic precaution is a dismal one.
On the other hand, those African hospitals are keenly sensitive to the existence of poverty as well as to the culturally rooted needs of families to share in the care of their own sick. Pregnancy and childbirth are regarded and managed differently in rural West Africa. Women with few exceptions are either unfamiliar with or unaccepting of the principles of birth control. As in other undeveloped countries with high mortality rates for infants and children, fertility is an invaluable asset. In such areas children are a form of insurance against the infirmities and dislocations of old age. Nigerians believe that children cannot be regarded as permanent members of the family until they have survived the first six years. Thus, pregnancy and childbirth recur without planned interruption for the full reproductive life of women. Community health hazards exist for everyone in rural Africa. In some measure, at times mercilessly, biting insects left their marks on all of us. Falciparum malaria is ubiquitous. Among the expatriates daily or weekly doses of Chloroquine are almost fully protective. The African’s immunity either completely protects or mitigates the severity of infection. The control of human traffic within rural hospitals is virtually impossible because families are expected to serve many of the physical needs of their members; bathing the bedridden, emptying bedpans, mopping up the soils of visiting infants, encouraging adherence to schedules of orally given medications left by nurses at the bedside and above all feeding patients. Also, because no government or mission hospital offers food other that the parenteral (feeding intravenously) variety, the nourishment of the sick depends entirely on visitors. Every rural hospital provides for the family to cook. Stone fire places are quickly assembled from local materials. Women and children are the traditional wood gatherers, finding wind-fall logs abundant in the adjacent forest. Food stuff is purchased each day in the village markets.
Preventive medicine is virtually nonexistent in these areas. Prenatal care by midwives is offered at scattered clinics. Immunizations are a variable part of their services. A single injection of tetanus toxoid for the newborn is given with greatest consistency. Children born in isolated villages are at high risk of tetanus as a consequence of the widespread custom of cauterizing the cut umbilical cord with dung-contaminated soil.
My experiences with death were very different. Sparing no age in rural Africa, death is regarded as an integral part of the continuum of life. It is an event that appears less threatening than for westerners. Grief, as we know it is brief and surely softened by the lively and noisy festivities involving drinking a large amount of alcohol through the night before the burial of the deceased. The deceased are wrapped in sheeting by the hospital staff and, when possible, transported by the family on foot to the home village. For long distances a bush taxi may be hailed and marked as a hearse, not for hire, by decorating its front with palm fronds. For visitors communication may pose a different problem. In Nigeria the official language is English, modified to pigin-English. This dialect is more recognizable as an English variant by some familiar words than by its structure. Sometimes leaning heavily on the interpretive skills of the nurses, this three-party system elicited information clearly. As the patient numbers made me focus interrogation mainly on the primary complaints, on occasions these were conveyed to me rather colourfully. For example, two common clinical symptoms in rural African males are diarrhoea and impotence. My accompanying nurse would receive the question about bowel habits from me. Her face beautifully innocent, she would ask the patient, “You no de shit fine?” Or, from the same radiant countenance, in response to my question about sexual function, emerged her direct inquiry: “Your ting, it no wake up so fine?”
The total experience in Nigeria were however richly rewarding personally and professionally. The exposure to the vast variety of pathologic conditions always
a measure of excitement and challenge. The contacts with the population desperately in need of modern health services of all kinds and their show of gratefulness for modest help by a caring foreigner provided me the greatest of satisfactions. For those readers who would regard as adventure a shorter or longer brush with another world, the opportunities are multitude in every undeveloped corner of the earth. The returns on a small investment of time and professional skill are nothing than a bumper harvest of goodwill.
Author Dr R M Abraham (Reina) is MBBS with Postgraduate diploma in Anaesthesia from the West
African college of surgeons and Postgraduate diploma in Public health from the London school of hygiene
and tropical medicine. She has worked at university teaching hospitals in Anaesthesia in Nigeria,
Republic of Benin and Ghana for a combined duration of nearly 15 years. She also had brief working
stint in Kerala, India exposing her to a little bit of paediatrics. For the past three years she has been
working at Nelson Mandela School of medicine, UKZN Howard College, Durban, as a Clinical skills
Clinician and facilitator to the undergraduate medical Education program. Her hobbies include reading
medical books to keep up with the rapid changes in the medical field. She loves cooking, housekeeping
and travelling around the world for pleasure.
By Dr. R M Abraham