In the following piece, doctors Josh Hulman and Helen Wanstall talk about their time at Ronald Ross General Hospital, the main hospital in Mufulira, so named after the clinician who became Britain’s first Nobel prize winner in 1902 for discovering the mosquito transmission of malaria
Here is their story…
While you were having an election, we were having an elective…
Final year Medical School students go on electives. But not all of us go to Africa, and not all of us go to developing countries. But when Helen and I heard, by chance, about the MMTA bursary for Zambia, we leapt at it. We wanted to learn how populations in different parts of the world experience tropical disease and infections we would normally only read about in text books. Our specific aim was to gain better knowledge of HIV, Malaria and TB, and see how developing countries cope with scarce resources and underfunded healthcare systems.
Our Zambian Diary
Getting there: There are no direct routes from London to Zambia – let alone Mufulira. So we travel via Nairobi, with a six hour stop-over, before heading onto Lubumbashi in DRC, and then to Ndola in the Copper Belt.
Our host: Waiting for us is Dr Charles Chiponda, ‘Medical Officer in Charge’, Mufulira Region, who is to look after us. The journey to his home gave us a first taste of Zambian life.
The roads: Potholes like craters. Zambian style driving (different). Most Zambians go round on foot or by bike. Locals compete for space on the road, squeezing too close to cars for comfort.
The goods, trade and food: Charcoal is transported by bicycle. Cycles here are used as a trolley. The charcoal is imported into Zambia from DRC. Mealie meal (ground maize) travels in the other direction. This is the staple food of Zambia. But mealie is worth double or triple in the DRC. The border guards attempt to stop the food leakage as it poses a risk to Zambia. DRC has a bigger, hungrier population. Despite this, every day from Dr Chiponda’s home, 6km from the border, we see men carrying sacks over the soft areas of the frontier. If mealie meal runs out in Zambia, people will struggle. It is a big issue. But the trade continues, night and day, regardless of heat, hunger, illness or monsoon.
The Chipondas: We are made most welcome and introduced to local Zambian cuisine, including Nshima. This is cooked ground maize served with a variety of delicious stews and accompanying dishes. Another favourite is african baloney (Helen’s favourite), and ground-nuts (Josh’s favourite).
At the hospital: It is the day after our arrival and we have acclimatized to the 30°C heat. It is time to work and we start our first day at Ronald Ross (RR). RR is a ‘Tier Two’ state hospital serving the Copper belt. It receives patients from ‘Tier One’ front line hospitals.
Our Supervisors: We meet the Medical Superintendent before meeting Dr James Matabile (Head of Clinical Care) responsible for our placement.
Our work: Helen and I choose to split up. (But not permanently). Helen goes to the female general medical ward and pediatric. I go the male ward. Dr Tshula Tumba is Helen’s supervisor. She is a general doctor who trained in the Congo and has been working at Ronald Ross for a number of years. Her special interest is HIV medicine. She is also able to carry out numerous surgical procedures – a true general doctor. When she is on call, she has to treat both medical and surgical patients without support. This would not happen in the UK. In Britain we rely on clinicians with specialisms and make choices about our career early. In the UK, a surgeon will not be asked to attend a medical patient, and nor would a medical doctor be required to perform surgery. But Zambia has no choice. The versatility of Zambian medics comes from a necessity caused by chronic staff shortages. Ronald Ross is meant to have 16 doctors made up of consultants and specialists. It currently has two specialists – a general surgeon and an ophthalmologist; as well as seven non-specialists on a level with core trainees in the UK.
UK and Zambian health compared: The first week at Ronald Ross is quite a culture shock. Having just finished our finals at medical school, we find ourselves in an environment in which a lot of knowledge doesn’t apply. In a typical day in the UK, we might treat heart disease (such as angina and high blood pressure), lung disease (such as chronic obstructive pulmonary disease (COPD) and asthma), diabetes and cancer. In Zambia, the majority of patients present with complications of HIV. Although HIV is prevalent in the UK, the infection is usually caught early before it can damage the immune system. In Zambia, patients come to hospital with a wide range of opportunistic infections, such as meningitis, TB, specific forms of cancer and parasitic liver abscesses. Meeting many people with diseases only rarely seen in UK and with no experience of how to treat them was difficult. This, however, was the point of the medical elective – to experience medicine of which we have little experience. Within a few days we feel more confident to see patients, coming up with diagnoses and treatment plans to present to doctors. The patients show extraordinary resilience. A lot of patients are extremely sick, with very serious infections and just receive the basic treatment available; but they still get up and start walking about
Going down the mine…: In the first couple of weeks, we see miners who have developed industrial lung disease. This is a consequence of breathing in particles released during the mining process. I want to see what Mopani is doing to alleviate this. When we go down the mine I am pleased to see that the underground workers are wearing respirators. We are shown, at about 1km depth, a well-equipped underground clinic with sufficient equipment to manage most emergencies (it is better equipped than parts of RR, but much smaller).
Malcolm Watson and Ronald Ross compared: Visiting Malcolm Watson (MW) (owned by Mopani) highlights the difference between government hospitals (Ronald Ross) and private ones (Malcolm Watson). Malcolm Watson’s buildings are renovated. The hospital is clean, spacious and well-equipped, with lovingly tended gardens – but there are very few patients.
We are told MW provides services for the community – a free cervical cancer screening program, free malaria eradication program, free ambulance service and free HIV treatment clinics. Although we have spent two weeks at RR, we haven’t heard anything about them. We have been told to tell patients, if referred to MW, that they will have to pay for diagnostics and treatments.
The doctor at MW, when asked about the uptake of cervical screening, tells us it is disappointingly low; only a few patients a month. And yet, cervical cancer is a big problem in sub-Saharan Africa. HIV increases the risk of women developing cervical cancer, usually presenting too late to be treatable. A program like this, if properly rolled out, could be a life-saver.
Why are Malcolm Watson’s mine-sponsored services not taken up?: After my visit to the mine and Malcolm Watson, we try to understand why people in Mufulira are not taking advantage of the free service. The issue is people believe that the services are not free and a charge will be incurred if you do not work for the mine. The mine does not appear to dispel this or promote the free services. We are told that if you try to use the ambulance service you will be asked whether you are employed by the mine. If you are not employed by the mine, you will be asked to contact Ronald Ross. It is a shock to us to see such health inequality in Zambia.
Conclusions: Since our return to UK we have tried to think how to improve this inequality. Our conclusion is ‘public health promotion’. If the offered services are not sufficiently promoted by the mine, can another body do so? Working with community leaders, with staff at Ronald Ross and using advertisements to promote the ‘free’ services provided by the mine perhaps could be the answer.
In terms of helping Ronald Ross, the clinical head of the hospital was interested to hear about our experience and to explain his struggles. He is passionate about what he does. It is an extremely difficult job. He has to manage the hospital and act as specialist surgeon at the same time. We conclude that the UK side should stay close and hear what is needed to focus donations of equipment for maximum benefit. He struggles with the lack of specialist doctors. This is why doctors have to be broad, not specialist to provide medical care across medical, surgical and pediatric patients. Complex medical issues must be referred to bigger hospitals, further away, with consequent risks. So, the addition of specialists or targeted equipment would allow the hospital to offer more treatments locally and improve education for the current medical staff.
Thanks to MMTA: We want MMTA members to know that this medical elective was everything we wanted it to be. We saw how healthcare is managed in conditions rarely seen in the UK. We wanted to immerse ourselves in a different culture and understand health provision in sub-saharan Zambia. We have learned a lot. We improved our clinical skills. We learnt that personal history and examination can lead to diagnosis when blood tests and other local diagnostics are less reliable. We saw hardships that both patients and doctors deal with on a daily basis.
The medical elective comes at a time in medical school when everyone is struggling for money. The bursary helped with flights, food and accommodation – and really does make a difference.