Download Medical Elective in Livingstone, Zambia

Livingstone General Hospital, Zambia
01/01/08 – 24/02/08
With thanks to the Yette and Boris Glass Foundation
Words: 3681
Upon independence in 1964, Northern Rhodesia changed it’s name to Zambia. Zambia a land-locked south
central African country and has a popultion of approximately 11,477,447 (jul 2007). It has one of the
highest infant mortality rates in the world with a rate of 100.71 deaths/1,000 live births, and the life
expectancy is a mear 38.44years. The HIV rate was estimated to be about 16.5% (in 2003) in the whole of
Zambia, but is probably considerably higher in Livingstone due to its proximity to the borders of
Zimbabwe, Namibia and Botswana thus increasing traffic-it is also known to have a high level of
prostitution.
Although literacy rates are reasonable at 80.6% (in 2003), unemployment rates are very high, and thus the
vast percentage of the population, are living below the poverty line. Zambia ranks low in the UNDP’s
2004 Human Development Index, at 164 out of 177countries. In 2005, Zambia qualified for debt relief
under the Highly Indebted Poor Country Initiative, consisting of approximately USD 6 billion in debt relief.
Today Zambia receives trillions of pounds worth of aid, which to be honest is quite hard to see where it
goes. However, the anti-retroviral therapy (ART) program appears to be a huge success, and most people
with low CD4 counts are in fact on the drug regimen. The main problems encountered seem to be
attributable to the lack of understanding about the disease and medications, but there is a strong desire to
learn more. The stigma surrounding HIV/AIDS is exacerbated by the doctors’ use of euphemisms such as
“reactive” and “non-reactive”, instead of openly discussing the patient’s HIV status. In my opinion, stigma
could be decreased by openness and discussion about the disease.
In Zambia, the health service is only free to a minority of people and the rest have to pay a small fee. The
hospitals, although supplied with very competent and clinically excellent Doctors, are lacking even the
most basic of supplies and equipment. During my time in Livingstone, I have witnessed children dying
from easily preventable complications and by having some basic supplies; a huge impact could be made on
the lives of these people. The main illnesses that are still big killers, after HIV/AIDS, include malaria,
tuberculosis, diarrhoea and pneumonia.
Livingstone General Hospital
Livingstone general hospital was built in 1907 for the whites and Batoka was built in 1906 for the blacks.
After independence in 1964 the two sites merged and Livingstone became the surgical and obstetric block
and Batoka came the medical, psychiatric and paediatric block. The hospital has about 300beds
During my stay I spent most of my time on the Paediatrics ward-‘Bindi’ and on infectious diseases on the
isolation ward. My responsibilities would include doing the ward round every morning, writing up my
findings, ordering limited investigations and prescribing medications that were in stock at the hospital
(which was very limited).
The state of the hospital leaves much to be desired: it’s dirty, there were flies and insects everywhere, sand
over the floor, cots and beds that were falling apart and rusty with the sponge mattress dirty with lots of
holes. Supplies are limited, you’re lucky to receive two pairs of gloves in a day, and forget about washing
your hands between patients. I’ve also witnessed nurses take rectal temperatures, wipe the thermometer
with a tissue, then put it in the mouth of the next patient. There is no concept of good hygiene, which is
especially worrying since most people in the hospital are immuno-compromised. There also appears to be
no such thing as privacy or confidentiality here, there are no curtains around the bed and lab reports are left
on a table for anyone to see. Peoples HIV status were referred to as ‘reactive’ or ‘non-reactive’ to whether
they were HIV positive or negative respectively.
This was in an attempt to keep the information
confidential, but it also meant the disease was not talked about-it appeared to be a taboo subject.
Medications are all kept in plastic tubs and plastic bags that had seen better days with grubby hand written
labels. There are no suspensions so the pills are crushed and mixed with water if a child will not swallow
them. The government funds the medications, but often there are shortages so the patients have to buy
them if they can afford to do so.
I decided that I could not work on the labour wards after seeing the practice. In Zambia women are not
aloud to make a sound when delivering, they must keep silent so they do not scare first time mothers. If
they scream they get slapped-and quite hard! There is no pain relief given and even the caesareans are
done under local anaesthetic opposed to a spinal or epidural. To me the labour ward was a torture ward and
I wanted no part in it.
On my second day on the children’s ward a mother alerted us to her sick 2month old baby, the baby was a
horrible pale colour, and was in obvious respiratory distress, with nasal flaring, head nodding, grunting,
sub-costal and intercostals recession and a respiratory rate of 72/min. The was no oxygen or medications to
help the child, the doctor just listened to the child’s chest and asked for some dextrose. The doctor gave the
baby 10ml of dextrose and about three minutes later the child went into respiratory arrest, and then cardiac
arrest. There was only one ambi-bag on the ward with one size face mask attached that was too big to
make a good seal round the babies face. The baby’s chest did not rise with each inflation mask so I asked if
there was a guedel airway or tube to intubate the baby but there was none. There was no adrenaline or
defib pads, there wasn’t even an ECG machine to check the rhythm of the heart! After four or five rounds
of what the doctor called CPR the doctor covered the child with a blanket and walked off without saying a
word or even looking at the mother, I tried to approach the mother but was sternly steered away by one of
the nurses. To me, having the knowledge that if these children were in the UK they would stand a better
chance made me feel incredibly guilty. We lost approximately four children a week and each time it never
got any easier. To me this was the worst part of the placement, and something that will stay with me
forever.
The objectives I set before my elective were:
1.
To practice common skills such as history taking and examination
2.
To gain knowledge and experience in tropical medicine/infectious diseases
3.
To gain knowledge and experience in nutritional disorders
4.
To develop an insight and knowledge of living with a terminal illness.
History taking and examination:
While on the wards at the hospital, my main responsibility was to assist in the ward round each morning. I
had the choice of either joining the doctor in charge of the ward in reviewing the patients, meaning I could
get some bedside teaching; or I could assist by reviewing the patients myself and just asking when I needed
help; or I could see patients before the doctor arrived to present on the ward round. Over the 8 weeks I did
a good combination of all three options.
The histories that the doctors took were very different to that of a western doctor. They were very
simplistic concentrating mainly on the current problem faced by the patient. Examinations were very
similar and not always routinely done. When I saw patients myself I could take a reasonable history
(language was sometimes a barrier-but there was usually someone about that was able to translate for me)
and practice any examination skills, as you would do in the UK. There were plenty of clinical signs in
most of the patients, which made it more interesting and helpful.
What I found interesting while on the children’s ward was that if people did not have HIV, malaria, TB or
malnutrition the doctors became stumped on what was wrong with them. When a patient came in with an
unusual rash, or a fever and they were found to be HIV positive, the rash/fever was put down as a HIV
related illness instead of looking into what was actually causing the rash or fever. I saw a 13-year old girl
that presented with a unilateral rash affecting the right side of her face below the eyebrow down to the jaw.
The rash was not raised, had a well-defined edge
and was black in colour. The patient said it did not
itch and had been present nearly two months but
was not improving or deteriorating. She had ptosis
of the left eye and also had a few circles or the
same looking rash on both her palms and soles of
her feet.
Other than having a low-grade
temperature and being HIV positive she was well.
She was currently on ART. The only investigation
this girl got was a FBC, which showed she had normocytic anaemia and a lymphopenia; everything else
was in the normal range. She got 1 unit of blood and was discharged home with a course of antibiotics, still
worried with no explanation. The same girl was admitted 1 week later with seizures. It’s unfortunate that
tests out here are so limited.
Tropical medicine/Infectious diseases:
I saw and became accustomed to a wide variety of infectious diseases mainly attributable to opportunistic
infections in HIV/AIDS.
While dealing with HIV and AIDS patients I came across some interesting misconceptions. A lot of people
believe that HIV is only a disease of Africa-even a fully qualified nurse with years of experience asked me
if that was true and told me that a lot of people believe that Western countries have the cure for HIV but are
keeping it to themselves to make Africans suffer.
I would estimate that approximately 75% of the patients on the children’s ward have HIV/AIDS. The
hospital is now a Centre of Excellence for HIV so I was given good teaching on the topic and gained a lot
of experience in the subject.
While I was in Zambia the issue relating to the depot and links to America impregnating it with HIV arose.
This resulted in the depot being completely withdrawn from the country, leaving the only forms of
contraception as condoms (which are not used if you are married) and the oral contraceptive pill (which
cannot be concealed from the partner). As a result of this misunderstanding there will be a lot of unwanted
pregnancies, and the depot has still not be re-instated as the story is still ‘under investigation’.
TB was very common in patients with HIV and also malnutrition. I have come accustomed to the
presentation of the illness and sending samples for AFB and prescribing children treatment.
Malaria-it was interesting that although most patients coming in with a temperature and headache were
suspected to have malaria, most of the peripheral blood films came back negative. It was interesting that
one of the doctors went to a national conference about malaria while I was out there, they were told that
although Zambia is a high risk for malaria, Livingstone itself was almost malaria free as the vast percentage
of peripheral blood films were coming back negative. One point that does come to mind is how they keep
the samples-they are left on the side for an hour or so in the stifling heat before they are transferred by hand
in direct sunlight to the very unsophisticated lab. It is also interesting to note that most people with the
symptoms of malaria that are commenced on treatment recover after a couple of days on the medications-is
this coincidence or is it the natural course of a viral illness? I have my suspicions both ways! I’ve seen
FBCs done on a child two days running because the first FBC results are deranged so they recheck them
and amazingly the results are always incredibly different. I feel that good clinical judgement is very
important over here.
Nutritional disorders:
I was actually surprised at the numbers of children that I saw with malnutrition. In the hospital there were
two side rooms with 3 cots in each dedicated to children with malnutrition and these were always full then
there would be an additional 5-6 children in the main ward.
On the children’s ward there was an equal split between children with Marasmus and children with
Kwashiorkor, there was no rule on which type of malnutrition responded best to the treatment, but it was
noted that children with HIV generally didn’t do so well, and it was mainly these children that we tended to
loose.
I became very slick at prescribing the child adequate medication on admission (antibiotics, vitamin A and
folic acid) and calculating the volume of F75 or F100 that they would require for each four hourly feed so
they received adequate calories without being over fed.
What shocked me the most was watching a mother feeding her child. If the child refused to feed the
mother would hold the child’s nose and pour the milk into its mouth, choking the child. Most of these
children are –4SD below their weight for height and so are immuno-compromised as it is, the last thing
they need is a chest infection from aspirating on the milk as I saw happen too many times, usually ending in
the child going into septic shock then respiratory failure and dying.
When doing the rounds in the morning, containers at the side of the bed would be still be full with the
F100/F75 prescribed three hours earlier. Some children when offered the milk by us drank readily, which
made you wonder why the mother had not been offering the child the milk. As a contrast some children
refused the milk and the mothers did not force them. These mothers would refuse naso-gastric tubes as
they claimed it would kill their children.
In the community, practically every child you see has the appearance of either Marasmus or Kwashiorkor,
it’s quite disturbing.
Terminal illness:
The main terminal illness that I encountered was AIDS. I got a good insight into what it must be like to
live with a terminal illness, I visited numerous sufferers in various stages of the disease each presenting
with different opportunistic infections. I found it incredibly interesting that when I was visiting these
patients in the community, the home-based care ladies would not tell me that they had HIV instead they
would say that this patient has been on TB medications for two years, which actually turned out to be ART.
Some of these patients I think believed that the medications they were taking were indeed for TB and not
HIV. Very few people would openly admit that they have HIV. This does not do anything to help the
stigma surrounding the disease.
Community projects that I got involved in:
Home-based care:

Maramba

Linda

Mwandi.
These are three districts within Livingstone which have a home-based care programme established; in each
of these districts there are several zones where the team visit on different days. The teams consist of 1025volunteers from the community that keep a record of patients in the area requiring palliative care,
counselling or advice, and are informed by members of the community if someone is sick and cannot afford
to get themselves to the clinic or hospital.
For myself, home-based care involved spending a morning or afternoon with the team, visiting people in
their own homes either doing a general check up on the patient, offering people advice or assessing patients
and either providing them with some basic medication from the limited supply that I would carry, or
arranging transport to get the patient to hospital. Unfortunately language was often a barrier even with the
home-based care volunteers translating, so getting a full history was incredibly difficult, and as for
examination, well I did the best I could in the circumstances-bearing in mind that most people I saw lived
in very cramped mud huts, with no furniture and poor lighting-not to mention it was rainy season so the
floors were often muddy and wet. This gave me a real eye opener. I would love to attach some photos here
but I felt too guilty pulling out my digital camera to get photos of peoples homes when they couldn’t even
afford to feed themselves properly.
Teaching:

Home-based care volunteers-I set up this project after having been out on a few sessions of homebased care when I realise that the volunteers have very limited medical knowledge but have the
enthusiasm to want to learn. Once a week I would go out to Maramba farm and meet with about
fifteen of the home-based care volunteers and teach them. We worked through a range of topics
starting on vital signs through to talking about the most common conditions that we came across
in the community, which included HIV and AIDS, TB, malaria, respiratory tract infections,
epilepsy and fits, diarrhoea, vomiting and dehydration, high blood pressure and diabetes. I also
encouraged them to address any misconceptions that they come across in the community. A lot of
these volunteers have had little schooling so the level I taught at was very basic. This I found to
be very rewarding, and I was completely speechless when I said goodbye to them all they all sang
me an African tribal song and danced for me. Even the men joined in which is a real sign of
respect. I’ve asked African Impact to continue this programme if they get anymore medical
volunteers as the home-based care team were incredibly keen to learn.

HIVE- (HIV education) is a programme set up by African Impact. Here about 30 women from the
community meet up twice a week for five sessions to get taught about HIV by us the medical
volunteers (of which there are three). We work through a programme with them covering what
HIV is, how it is transmitted and how
to protect themselves, how it is
diagnosed,
treatments,
opportunistic
infections, stigma and discrimination
surrounding the disease.
Some local
volunteers perform a drama/drumming
show to recap the information, and then
we test them and give them certificates.

Adult literacy- I only did this on one
occasion. African impact send volunteers out to Maramba farm two set afternoons a week. The
club is available to anyone that wants to come-many people that come have very limited English,
and our responsibility as a volunteer was to listen to people read out of a book of their level, and
correct and explain things that they do not understand.

Mwandi reading club-I only did this
project on one occasion as well.
This
involved going to Mwandi school one
afternoon and sitting with eight children,
encouraging them to practice their reading
and
writing,
challenge them.
setting
them
tests
to
Maramba Clinic:
This is a very busy clinic again with poor resources. My work here involved me mainly triaging the
patients. Doing the vital signs and writing a brief history for the clinical officers to expand on. I only did
this on a couple of occasions as I felt I was of more use and that I would learn more in the hospital.
Maramba old peoples home:
The home itself left a lot to be desired with the residents living in garage style rooms that definitely had
hygiene issues and an interesting character for a manager.
This placement involved me doing a ‘clinic’ for unwell or chronically ill patients. There was a little office
with a small couch that I used to see people. Each time I visited there were usually about 6 people that
needed attention. It was interesting as a couple of the residents would return to see me every time I visited
asking for medications when they had nothing wrong. One of the managers pointed out to me that a lot of
the residents see the medications as food, which I found quite surprising. I saw one gentleman that needed
a catheter change-it had been in place for over two months and was beginning to leak! The urine smelt
awful and on questioning the manager was complaining that the gentleman was always confused but had
been for the last 4-6weeks! The gentleman not surprisingly was found to have a urinary tract infection after
I sent a sample to the clinic! The difference in the patient after a short course of antibiotics was amazing!
The elective period is about enjoying something a bit different. That is exactly how I would describe my
experience. I was lucky to experience working in the hospital and also in the heart of the community,
immersing myself in the local culture and traditions.
I feel that I have got so much out of my placement, not only educationally but also personally.
I have come to realize that throwing money over here may help in the short term but won’t change things.
What will make the ultimate difference is people putting time and effort into educating people and buying
or providing the tools and equipment to do so.
Halfway through the placement I applied to the Ministry of Health in Zambia to start some research on HIV
incidence and awareness in Livingstone, this was approved a couple of days before I left so is being
conducted at the moment. As a result of my experience Bethany Birkelo (a pre-medical student) that I
worked with, and myself have decided to set up a charity called ‘Bindi Just Health’ to help provide the
hospital and community with educational and medical resources, more information can be found at our
website www.bindijusthealth.org
There is great potential and willingness for change, and we believe these projects will be successful. I
would strongly advice anyone with an interest in third world issues to take their elective in Zambia.
The only regrets I have are not being able to do more for these people.
References:
The CIA world fact book available at https://www.cia.gov/library/publications/the-worldfactbook/geos/za.htmlMedical Elective in Livingstone, Zambia