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Views from
the hospital
The muddy
path to Kumbo
Kumbo
The hospital has around 300
beds divided into male, female, cardiac, maternity, paediatric, surgical and
TB wards. Whilst medical care is provided by the doctors and nurses, all
other care i.e. washing, feeding, grooming is carried out by the patient’s
guardian, often their spouse or child, who stays with them. At night time,
guardians sleep on a piece of foam underneath the patient’s hospital bed.
During the daytime, most
patients and their relatives sit outside in the hospital’s beautiful garden.
This is especially encouraged on the TB ward as Mycobacterium
tuberculosis, the bacterium responsible for causing TB, is immediately
inactivated in UV light.
The
hospital gardens
Each patient has to pay for all the medical care and
medications they receive, including each time they are weighed or have their
blood pressure taken. The nurses are very skilled at balancing the best care
they can give with the financial means of the patient, although of course
this often leads to suboptimal care e.g. catheters not inserted when
necessary, critically ill patients not being monitored on the ward because
they can only afford the most minimal standard of care. Whilst I was there,
a new English nurse (whose speciality was intensive care) started on the
cardiac ward. On her first day she was very worried about a young female
patient who seemed to be in shock. She closely monitored the patient and
took her blood pressure every 20 minutes for 8 hours, whereas all other
members of staff seemed to be ignoring the patient. At the end of the day
she was devastated when I told her that the patient would be charged for
every single blood pressure recording she took, as she thought she was doing
the best she could for the patient.
When patients arrive at the hospital they are often
seen by the compound nurse, and it can be a day or two before a doctor lays
eyes on the patient. In the meantime, the patients are usually started on a
diverse list of medications seemingly to cover every possible medical
condition. Drugs include a mixture of antibiotics, quinine for malaria,
steroids (for some completely obscure reason), vitamins and valium. The
medicines are usually not medically indicated, but the patient has to pay
for everything they receive, whether it is necessary or not.
A real problem seems to be a lack of ongoing medical
training after graduation and the doctors and nurses have little access to
modern textbooks and learning resources. The doctors and nurses greatly
appreciated the use of my modern textbooks and were very interested to find
out about current medical practice in the UK. Interestingly, in one of my
textbooks it mentioned that Doxycycline, a cheap and readily available
antibiotic, had just been identified as an extremely effective treatment for
Onchocerciasis (a filarial worm infection of the skin causing river
blindness). The Doxycycline works by killing symbiotic bacteria in the
worms’ intestines, essential for the worms’ survival. The Cameroonian GP I
was working with didn’t know about this treatment option previously and
adopted this new therapy for his patients.
Onchocerciasis
My daily schedule
I rotated through male, female, TB, cardiology and
maternity wards as well as the HIV service and general practice clinic. I
worked from 8am until 2pm Monday-Saturday and also often did the “on call”
in the evenings.
In the GP clinic I saw patients on my own and admitted
them to hospital if necessary. On the wards I examined patients, performed
ward rounds and carried out procedures such as lumbar punctures and
thoracocenteses.
Examining
patients on the cardiac ward
Performing a lumbar puncture
I also did vaccination clinics, baby checks, antenatal
clinics and I helped with the general running of the hospital.
Giving a tetanus immunisation
Weighing
babies
Doing the
antenatal clinic
Cleaning the incubators
Outstation visits
I went on monthly outstation visits to Banten,
Wainamah, Djotten and Sabongida, which are rural communities surrounding the
hospital. This was a fantastic opportunity to see more of the stunning
countryside in Cameroon and also see patients who only had access to a
doctor once a month.
Sabongida is a village on the border with Nigeria which
is completely cut off from roads. We did an overnight visit there. The
journey involved 5 hours in a landrover along horrendously bumpy roads (with
4 adults, 2 dead monkeys, 2 sacks of sweet potatoes and our luggage all on
the back seat).
In the
landrover on the way to Sabongida
This was followed by a 1.5 hour trek by foot which was
fabulous. We had to cross 4 rivers, one by stepping stones, one by a swing
bridge and two using felled tree trunks. Unfortunately, at the end of the
trek we were caught in a terrible thunder storm and were absolutely drenched
by the time we arrived at the clinic.
The trek to
Sabongida
Once we arrived at the health centre, we soon warmed up
and cheered up when Madame Ita boiled up some lemongrass (grown outside the
health centre) to make lemongrass tea. The Sister also presented a freshly
made and amazingly still warm banana cake from the convent. For dinner,
Madame Ita cooked Jelloff rice over a fire. Although we were in the middle
of the bush with no electricity or running water, the Jelloff rice was the
best meal I had in Cameroon. After our lovely meal by candlelight, we
checked on a patient who was delivering silently (also by candlelight) in
the neighbouring room. This felt like we were in the 18th century
until Sara (a midwife) reminded me that the modern day NHS also encourages
the use of candles in the labour room to recreate a relaxing and homely
feel!
The health clinic at Sabongida (built with funds from a visiting Canadian
doctor)
The
delivery room at Sabongida
The view
from the Sabongida Health Clinic
The village of Sabongida
The next day at the clinic I saw all the
paediatric patients at the clinic.
Examining a
paediatric patient
Women and
babies waiting to be seen
Difficulties
One of the main difficulties I faced was the language
barrier I had with patients. Although the NW Province of the Cameroon is
English-speaking, in reality people speak the local language of Lamso
(incomprehensible) or Pigin English, which is very difficult to understand
and even more difficult to speak. Fortunately, a lot of patients also speak
French and I found this easier to understand, being the traditional “pure”
French that you learn at school. It was an added bonus for me to be able to
improve my French over 8 weeks.
Another difficulty was accepting the different
standards of care in the Cameroon compared with the UK. In the Cameroon,
people die from illnesses that are really very treatable. When I was there,
a man died from gallstones. Another very difficult thing to see was the lack
of effective pain relief. Two women with ovarian cancer and one man with metastatic Kaposi’s sarcoma died from their cancers with very little in the
way of pain relief. What they needed was a steady supply of morphine or
fentanyl.
Another major difficulty I had was the fact that
patients had to pay for all their medical care, and if they didn’t have
money to pay, they would be turned away. I met a pretty 29 year old woman
who I will never forget. She was wheeled into the HIV service clinic by her
husband and actually looked ok wrapped up in all her robes, but when she
opened her mouth it was thick with Candida and when she took off her clothes
I was so shocked to see she was a skeleton. I could see every bone in her
body covered in a thin layer of transparent skin. She had neither the energy
to stand or speak and her eyes were blank. Her weight had decreased from
75kg to 29kg. Plus, all over her body were scars from scalpel cuts. A
traditional cure for HIV is to have a witch doctor cut you with a scalpel
blade. Her husband had had her discharged from the hospital the week before
as he could no longer afford the hospital bills, so I suppose they had
turned to a witch doctor instead. At this consultation, he still couldn’t
afford to have her admitted, so the doctor sent them away without any
treatment, although the doctor admitted that she could possibly make a
recovery if antiretrovirals were instituted.
The HIV problem
Although I was well aware that Africa had an HIV
problem, the amount of HIV still shocked me. At the hospital it seemed that
everyone between the ages of 15-45 was infected. We made the diagnosis
several times every hour, more often than not on the basis of appearance or
the patient reporting strange chronic symptoms such as diarrhoea lasting
more than a few weeks. The most striking thing was that HIV affected just
the normal regular everyday people in Cameroon, including middle-aged women,
elderly men, young pretty girls. Everyone. With regular medication, these
people can carry on a normal life, but less than 10% of patients can afford
the 3 pounds/month to be treated. Furthermore, before treatment can
commence, patients must undergo the HIV diagnostic test and have full kidney
and liver screening tests, as well as a measurement of their white cell
count. All of this amounts to more than 20,000 CFA (£20) worth of
investigations, which many can’t afford. It seemed ludicrous to me that the
Cameroonian government didn’t see the benefit of supplying free
antiretrovirals to all.
One man I met, a lovely man, told me that he contracted
HIV because his younger brother had the disease and a witch doctor had cut
them with the same scalpel blade. Unfortunately, even at the convent, there
were nuns and priests selling a traditional cure for HIV which cost £15, the
same price as 5 months antiretroviral treatment.
The “cure” for HIV sold at the convent for £15. The label reads “also for
malaria, typhoid and menstrual cramps”
A 10 year old girl I met on one of the outstation
visits had the very rare condition of Cancrum Oris. She had end-stage AIDS
and was an orphan, although an extremely kind (yet very poor) woman in the
local village had adopted her, along with 11 other children. Because of the
girl’s deficient immune system, the normal bacteria in her mouth had been
able to proliferate unchecked and had caused massive necrosis which had
eroded her cheeks, gums and teeth. The woman couldn’t afford antiretroviral
treatment for the girl, but after the Cancrum Oris, free maize was donated
to the woman so that she could feed the child properly. 3 months after
starting maize, the improvement in the girl’s condition was miraculous,
showing the importance of good nutrition in the management of HIV. The
residual hole in her cheek will now never heal, but she is able to live with
it.
Cancrum oris, before and after feeding with maize.
Identified Needs
Charitable donations of drug packages often arrive at
the hospital from Europe and America, although I noticed that these drugs
were never given out to the patients for free, although the hospital
received them for free. Furthermore, because the hospital received a variety
of free drugs every month, they seemed reluctant to buy their own, and
therefore were often lacking in vital supplies such as oxygen tanks and
morphine. When I was there, there was only one oxygen tank available in the
whole hospital. I saw an 11 year old boy in respiratory distress die in
front of my eyes and only 5 minutes after the death did the oxygen tank
eventually arrive on the scene carried by 2 men from the surgical ward. I
also saw many people suffering with end-stage cancer with nothing more than
oral co-codamol for their pain, which was utterly ineffective. It would be
really beneficial if a charity were to ensure a supply of basic standard
drugs such as oxygen and morphine. As the hospital charges the patients
standard rate for the free drugs they receive, I believe it would be of more
direct benefit to patients if charities made donations that could not be
charged for. For example, donating modern medical textbooks to the doctors
and nurses and replacing equipment such as the rusty, aging incubators in
the maternity ward.
Personal goals
My clinical skills improved enormously at the hospital.
I became used to detecting large livers and spleens, heart murmurs and
abnormal breath sounds. I also became used to diagnosing TB, HIV and malaria
from clinical signs alone and I learnt to analyze grossly abnormal Chest
X-Rays, especially from patients with TB. I also saw some amazing and very
interesting pathology, such as the Cancrum Oris, laryngeal TB and an
enormous thyroid mass.
X-Ray
showing a pleural effusion in a patient with TB
A massive
thyroid goitre
Furthermore, I was able to learn how to do practical
procedures such as lumbar punctures and thoracocenteses (under supervision),
which in the UK I would not be allowed to do.
And finally…..
Upon my return to the UK, my overall memory of the
Cameroon is of the friendliness, humour, politeness and respectfulness of
the Cameroonian people, even in the face of such adversity. Although some
days at the hospital were very sad, I also remember laughing a lot both in
and out of the hospital. The elective not only taught me about clinical
medicine, but made me realize how lucky we are in the UK to have free
education, a free health system for all and to live in a relatively
non-corrupt country.
Having fun
in and out of the hospital
Making fufu
We made
Fufu with Okro soup
Sharing a
meal with my francophone neighbours
The chickens we had to buy for dinner
In the
hospital
Leaving for home
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