Long Live the NHS

Every day I learn something about the way culture, superstition, religion or tradition affect the care that patients expect and receive in hospital. For example with pregnancy. In Tanzanian culture pregnancy is hidden because being pregnant increases the mother's vulnerability to social or physical harm. If she miscarries or has a premature baby it might be thought she had attempted an abortion. Medical notes never state a woman is pregnant. Instead they will say she has not had a period for say, 9 months. There is no noise from the delivery ward where women give birth alone, without a sound or pain relief. When a baby dies during delivery mothers are not meant to cry or hold the child and often they do not get a funeral. Instead the mother has to bury them outside the village. It is very hard to work to improve the care that babies and children receive in a culture where newborns do not get a name for the first month of life because they are not yet a person. At the other end, when a patient dies there are no ambulances to carry the body home. Relatives pay for a bejaj (tuk-tuk) or a piki-piki (motorbike) to take the body back to their village. In the case of a piki-piki, the body is sat upright between 2 other passengers and driven home for burial. In the meantime, a simple mortuary is on hand - a raised concrete slab in a building with slit windows that has no refrigeration. Most family members prefer to be told that there is little hope for their relative so that they can get them home while they are still alive and easier to transport. Death is accepted in as stoic a fashion as birth. But very occasionally there is a terrible wailing from devastated relatives who have been told their son/daughter/father has unexpectedly died. At these times, we staff stand around awkwardly, waiting for the sudden outpouring of grief to be ushered away somewhere out of sight and earshot. Overnight deaths are presented in our morning meetings by announcing, "in ward 1A at 3am, the patient stopped breathing". This is enough to declare death because no resuscitation is ever attempted. What for, when a patient can't be intubated or monitored with any equipment more advanced than a blood pressure cuff? Around the hospital, patients sit on the floors of the open air corridors waiting for blood tests, waiting for outpatient appointments, waiting for prescriptions, waiting for their turn in theatre. Beds are lined up along the wall outside of theatre for those that cannot walk there by themselves, wheeled by their own relatives. Patients with open fractures or septic wounds attract the flies in the heat. Inpatients who require blood tests are sent to the laboratory to wait, maybe all day if the lab is really busy. Mothers and babies sit on the floor for hours, then return to the ward with their results and wait again until the next day when the doctors come around. Sometimes on the children's ward there are several patients to a bed, including the mama's and bibi's (grandmothers) of the patients, who come to take care of them and make them food. No meals are provided by the hospital.  If someone doesn't have a family member to cook, they don't eat. Relatives stay in a concrete accommodation block next to the hospital; a large room where everyone sleeps together under a bright fluorescent strip light. The chimneys are blocked and in the evening smoke from the cookers funnels out of the glass-less windows. At night the hospital doors are locked but you often see relatives passing packages through the holes in the walls to their family inside. Today, there was a 1 year old child on the ward who was struggling to breathe and desperately needed oxygen. They looked like they were dying to me. Mama wouldn't agree to treatment until her husband could be consulted. When he eventually arrived and approved, the nurses were reluctant to administer the oxygen because if the child died they would be blamed; the superstition being that if you give oxygen to a patient it will kill them.
Medication rounds consist of the medical attendants, or a nurse if the ward has one, standing at a table with a pestle and mortar, shouting each patients' name until they come and collect their or their child's drugs. Even if they had a caesarean section that day, the women come padding along from their beds, babies tied to their backs or attached to their breast. For the infants, all tablets are crushed and emptied into a small cup - few liquid medicines here - no doubt they get some of the drugs from the patient before them and who knows what actual dose they receive. Staff are always attending educational meetings and training sessions but whilst the NGO's that organise this teaching are well-meaning, they have little idea how things work on the ground. People go to these courses, eat the chicken offered at lunch, drink the sodas, catch up with friends, then go back to their work and never use or share any of the information they learn. And in their pocket they carry the 10,000 shillings (or more) that they get; per diems for attending the course in the first place.
Once you accept these challenges and the many others, it's possible to start making small inroads and changing things for the better. But it's polepole (slowly slowly) as they say in Africa and it's a long, sometimes frustrating journey to get the respect and trust needed before you can mend even one small thing. 
No wonder our placements are 2 years long. Nothing can be done in a hurry.

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