A year working at SFH

Dr’s Anna and Michael Maze
November 2007

We are writing this from our tent, 2000km south of Katete and a week after leaving St Francis. We first heard about St Francis as we were trying to learn as much tropical medicine as possible at the London School of Tropical Medicine and Hygiene. There is not much call for working knowledge on worms, malaria, HIV or TB in New Zealand and it was clear there were large gaps in our knowledge. We both knew that we wanted to work in Africa and that this knowledge would be useful, but we hadn’t worked out where exactly we would be putting it to use. We knew we wanted a reasonably large and well run hospital where we could focus on practising medicine rather than trying to set up or run a clinic, and we thought it would be easier if the country’s backup language was English. When we heard of a couple who were finishing their year at St Francis’ and had loved it, we thought it would be just the place for us.

We are two New Zealand doctors, 4 and 5 years postgraduate who are yet to enrol in specialist training ( we are now returning to New Zealand to get that sorted out). Partly accidentally but fortuitous nonetheless was the broad range of experience we had gathered before going to St Francis’ in the rural New Zealand hospital we had worked in during our post graduate years. Also incredibly valuable was the 3 month Tropical Medicine and Hygiene Diploma in London, which we would highly recommend to anyone planning to work in the Third World. (It is also an extremely fun 3 months!).

We arrived at Katete in October 2006 still unsure of what to expect: we were rather overwhelmed by the heat, noise and dirt of Lusaka. We arrived at the hospital late at night and waking up the next morning to the relative peace and greenness of the hospital area was reassuring. That impression was knocked around a bit as we had our orientation to the wards, clinics and on call. Luckily for us though we arrived at a time when there were plenty of doctors to share the workload and we found, as you almost inevitably do, that actually starting work is much less daunting than hovering on an orientation/observation schedule. As part of our orientation was spent in Theatre where we were complete ducks out of water, it is hardly surprising that the routine of a medical ward round was soothing!

Our work was based on the Medical wards and OPD. This suited us as we had very limited (basically none) surgical skills. The medicine was very different to anything that we had encountered before and we found it both challenging and enjoyable. The main challenge, which remained present throughout our time, was those patients who clearly had serious pathology which would easily be given a histological diagnosis at home, but who due to our knowledge gaps and lack of diagnostic resources had to make do with “best guess” diagnoses and treatment. Deciding to embark on potentially hazardous treatment without confirmation remained difficult for us. Balanced against this was seeing spectacular recoveries from near death. There are several patients in particular who we will always remember. The opportunity for ongoing outpatient care was also very rewarding.

The Sandy Logie clinic (HIV clinic) gave us the opportunity to see steady improvements of patients over the course of the year. Often we would first meet a patient with TB or some other opportunistic infection, convince them to get HIV counselling and testing and then follow them through the next few months, as they gradually regained their health on the anti-retroviral therapy that has revolutionised health care in the fortunate parts of Southern Africa.

We learnt a great deal during the year. Our understanding of the epidemiology of disease in the district improved dramatically. The mortality meetings were particularly valuable in giving us a chance to review notes, summarise trends and alter our clinical practice. The most important lesson that we learnt from this was the overwhelming prevalence of TB. The epidemic of HIV/TB co-infection accounted for the majority of deaths, but most recovered on treatment. The variable atypical presentation of TB/HIV disease makes diagnosis a challenge. We learnt (too often the hard way) not to rely on sputum results or chest X-ray findings only in the advanced HIV patient, but saw other patterns of severe weight loss, anaemia and ongoing fevers to guide us to the diagnosis.

We also enjoyed the experience of living in rural Zambia and learning Chichewa but regretted that we didn’t put more effort into learning it systematically. Having bought a 4x4 truck early during our stay, we made the most of the South Luangwa Game Park about 3 hours drive away and the lake and hills of Malawi. But weekends around Katete were also great, exploring the local area on mountain bike, wandering around the hills about 4km away and having barbeques in the evenings with the ever-changing but always entertaining hospital crew. We were also caring grandparents for our dog’s brood of pups.

It is amazing how quickly our time at St Francis passed. One year seemed like a long time when we arrived. Although we need to get back to NZ to progress through our training, we feel that just as we developed an understanding of the place, the people and the work it was time to go. We do intend to return and would enjoy contributing to longer term plans for the hospital. Sadly however, this will probably be some time away.