Elective Report

Stacey Chamberlain (U.S.)
March 2002

I spent two weeks each as a junior intern in each of the departments of pediatrics, general adult medicine, obstetrics and gynecology, and general surgery. 

My first two weeks were spent on the pediatrics ward. Most of the pediatric patients either had malaria or malnutrition (somewhere in the range from marasmus to kwashiorkor) or a combination of the two. Occasionally, there were other diagnosis as well, of course, including bacterial meningitis as well as a variety of infections in children who were most likely immunocompromised. Malaria is particularly rampant this time of the year during the rainy season. Mosquito nets are readily available, but at a cost of about $2.50, they are not affordable to many of the villagers. The infections tend to be much more severe in the infants, and the pediatric deaths were averaging about two a day while I was on service; 41% of these were attributed to malaria, 40% to malnutrition and 16% to pneumonia. There were 64 pediatric deaths in January alone which was 14 percent of admissions. The malnutrition was particularly severe this year as well due to poor rainfall last year with a bad crop. There is a country-wide shortage of millimeal which is the ground maize product which most people subsist on. Due to IMF restrictions, the Zambian government is not allowed to subsidize the mealiemeal for people to acquire it. In any case, it was very difficult and disheartening to see so many children dying in such difficult circumstances with little I could do as a physician to address major issues such as a national food shortage and the chronic problem of malaria. With the addition of the AIDS epidemic to the troubles of Zambia as well, the life expectancy has now plummeted from 50+ to a meager 43 years.

We saw neonates as well on a small ward which consisted of several light boxes where the babies were kept. The only available treatment options for them were basically aminophylline to stimulate respiration, antibiotics for suspected infection, NGTs for feedings, and IV glucose water (hypoglycemia is also commonly seen here with malaria and as a consequence of treatment with IV quinine). There is really no other basic life support, so babies born much before 30 weeks (or even some after that) do not survive. It is difficult to determine accurate gestational ages here as well since none of the mothers have had antenatal ultrasounds as part of their antenatal care. The light boxes are sprayed about every six weeks with insecticide, as available, but often this was not enough to keep the cockroaches at bay which are reported to sometimes nibble on the babies’ toes and cause infections.

My second two weeks was spent on the adult medical wards. Of adult medical inpatients, approximately 70% are estimated to be HIV positive; the overall prevalence in the country is not clear but is estimated to be as high as 25% in Lusaka but was only 8% last year for all antenatal patients checked at St. Francis. We have the means of testing for the antibody here, but more sensitive and specific tests are not available. In patients suspected of being positive, they receive pre-test counseling about the test and the disease. If they agree to the test, they will receive post-test counseling when the results are made known to them. There is a huge stigma here about HIV and AIDS, and even many health care practitioners will not talk openly about it, and various euphemisms are used such as “RVD” for retroviral disease or even “new” disease. Many patients refuse to be tested because if they turn up positive, they may be deserted by their families. Many schools in the country refuse to teach about AIDS, and efforts by the government are poor to promote further education. As a result, there are many misconceptions about how it is spread and how it is cured. Even some trained nurses have said they prefer showers to baths because they are afraid of catching HIV in bath water. Another common, and scary, myth is that for a man to cure himself of it, he must sleep with a virgin. There are virtually no antiretrovirals available in the country, and as preventative measures, at present, are relatively poor, the outlook remains grim as this disease is wiping out an entire generation.

As a result, I saw many patients with a variety of illnesses that were obviously HIV related. The most common being TB, which may be obvious given that there is an entire ward dedicated solely to TB patients. Kaposi’s sarcoma is common as well, and then the usual host of pneumonias and meningitides. Wasting, oral thrush, and herpes zoster were also fairly common suspicious signs. The most common non-HIV related complaint seemed to be abscess. These patients were often kept on the medical ward until taken for surgery, then transferred to the surgical ward. Another interesting and relatively common diagnosis was of organophosphate poisoning from local insecticides. Some of these were suicide attempts, and some seemed to be accidental where the same container was used for food that had contained an insecticide.

Diagnostic testing is currently limited to Hb, serum K and Na, CBCs, BUN (no Cr), blood smears (most often done for malaria), bleeding/clotting times, ESR, urine microscopy, CSF evaluation (including Gram stain), and since I’ve been here, they’ve started doing urine and blood cultures. Other available studies are Xrays and ultrasound. We are the only hospital in the Eastern Province with an U/S, and reports are taken with a grain of salt as the ultrasonographers have not been officially trained and are just learning with experience. For patients in dire need of a CT scan (in which something treatable is suspected), there is a scanner in Lusaka, and on rare occasion, a patient will be transferred there if they are likely to survive the six hour drive.

Medications are limited as well. The most commonly used antibiotics are penicillin, amoxicillin, chloramphenicol, TMP/SMX and metronidazole. As second line agents, we also have IV gentamicin, cloxacillin, and erythromicin. There are no cephalosporins or fluoroquinolones. There is also no amphotericin, so patients diagnosed with cryptoccocal meningitis are basically sent home with their dismal prognosis.

After medicine, I spent two weeks doing obstetrics and gynecology. Cesarian sections are performed by all physicians (excluding the pediatricians), not only the gynecologist, depending on who is on call. Patients who have a variety of risk factors (often they have had several previous stillbirths when trying to deliver at home), are instructed to come to the hospital at about 32 weeks gestation, and are called “waiters”. They are not admitted as inpatients, but they have regular checkups and stay on hospital grounds, so that they will be nearby should they go into labor. During their waiting period, they attend some educational classes instructed by the midwives. There are no Dopplers to listen to fetal heart sounds; instead small metal cones are used (you put your ear to one end and the other end against the patient’s abdomen), and as there is no continuous graphic monitoring contractions and corresponding fetal heart rate, fetal distress is more subjectively measured by any decelerations, and failure to progress is the most common indication for section.

Many of the gyne surgeries were for vesicovaginal fistulas, usually attributed to prolonged obstructed labor. The vast majority of patients seen in gyne clinic present with the complaint of infertility. As there are no hormone assays available here, a standard workup consists of semen analysis and possibly a D&C to microscopically evaluate the endometrium for proliferative changes to indicate ovulation and/or an HSG if indicated. Culturally, women who cannot bear children are scorned as large families are valued, and as polygamy is legal, men will often take on second wives if they don’t have any children by their first. One new mother after just giving birth to her healthy son told me she was very grateful because her first two pregnancies had ended in stillbirths and her husband used to beat her for it; “now [her] marriage would be saved.”

My final two weeks were spent on general surgery, “general” covering quite a variety of procedures as described earlier. As would be expected, due to difficulties with costs of transport to even get to the hospital and other barriers including lack of any preventative care and preference of many rural people to try to see traditional healers before resorting to “Western” medicine, many conditions present at very advanced stages. I saw several stage 3 and 4 cervical carcinomas, a prostate the size of a large grapefruit, and an ovary, literally, as big as a basketball, all within only one week. Split skin grafting was commonly done for burns which were almost inevitably the result of patients falling on fires while having seizures (the very high rate of “epilepsy” here is likely due to neurocysticercosis). Fractures are extremely common as well with causes running the gamut from babies falling off their mothers backs to children falling out of mango trees to men who’d been beaten by the police or other inmates (local prisoners are often referred here). 

If at all possible, autologous blood donations for elective surgeries are preferred as the risk of acquiring transmissible diseases is quite high here. Blood is screened only for HBV, HIV, and syphilis, and only with Ab tests. Given the extremely high prevalence of HIV infection here and not the most sensitive testing, the risk of an acquired infection is estimated at 1%. There is also an extreme shortage of blood, in general. Many patients on the medical ward with hemoglobins as low as 3 had to wait to receive transfusions until they could find a relative to donate for them. Relatives are also relied upon to take care of incapacitated patients. As there are no nursing homes in Zambia, some patients have had to wait in the hospital until some relative could be found to claim and care for them. I also witnessed many children in the hospital being looked after by their grandparents as their parents have passed away, likely of AIDS.

Overall, I have had a very diverse and educational experience at St. Francis. As a secondary or tertiary care center (and I think partly due to the sheer number of patients I saw), I was able to see some rather obscure diseases which I had not come across before including Hurler’s syndrome, neurofibromatosis, osteogenesis imperfecta, and xeroderma pigmentosum (all of these diagnoses made clinically, of course, as genetic testing is obviously not available). I also gained familiarity with various tropical and/or parasitic diseases endemic here but not very commonly found in the States, including malaria, schistosomiasis, cysticercosis, hydatid disease, tuberculosis, Burkitt’s lymphoma, and hepatocellular carcinoma secondary to HBV infection and/or aflatoxin exposure. Other conditions presented in extreme states due to the common delay in seeking medical attention; these included cases of gas gangrene, tetanus, and very advanced carcinomas. Snake and crocodile bites and their associated infections were also new to me.

I feel that I also greatly improved my diagnostic skills and critical thinking skills by being challenged with a lot of responsibility without the availability of the usual plethora of diagnostic tests and treatments we have at home. I was able to gain procedural experience as well doing thoracenteses, paracenteses, lumbar punctures, and by often first assisting in surgical procedures. Regarding my own aspirations and professional future, this experience has been inspiring to witness the work of a few physicians and the integral part they can play in a place where trained physicians are so scarce, and there is a substantial “brain drain” of any trained medical personnel to foreign countries where salaries are more substantial. I appreciate the assistance of AMWA in allowing me to gain this valuable experience.

I would highly recommend this program to any other medical students who may be interested. One benefit for American students is that English is the official language here and is spoken by all the medical staff and used for all written materials. There are some 72 tribal languages spoken throughout Zambia, however, and the use of staff as interpreters is required with most patients. The accommodations are nice. I had my own room with attached bathroom (including shower and English toilet), but students often have to share a room depending on the number present. Meals are eaten with the few other resident foreigners and other visiting students and are provided by mess staff; the fee for room, board, and laundry is £5 per day (approximately $7/day). Students are accepted usually for a minimum of 6 weeks, and there is some flexibility as to which areas any student would like to spend their time in; I chose to divide my time into two weeks in each of the four major disciplines for the broadest exposure. Personally, I have also found the Zambian people to be extremely friendly and inviting, and I was able to visit one of the best game parks in Africa on one free weekend where I had an incredible safari.