From Elective Reviews - Niger - Hôpital de la SIM, Galmi, Republique de Niger, 2010 - Joanna Lovell
I spent seven weeks in a SIM (Serving In Mission) Christian Hospital in Galmi, Niger. My time was spread between adult medicine, paediatrics, obstetrics and gynaecology and surgery. I was also included in the 'On Call' rota for the Emergency Room (ER). It was a challenging time for many reasons. In terms of the work I was doing, for the first time I was responsible for managing patients, I was encouraged to make decisions on my own, and I had to get used to an extremely different health system very quickly. It was also my first visit to Africa, and my first experience of living in a truly different culture. However it was also an amazing opportunity to consolidate my knowledge and acquire new skills, as well as witness first hand what it would be like to serve the living God on a mission field such as this one.
Most of the care provided by the hospital was through the out patients' department (OPD). This functioned as the primary care system, patients presenting with a huge variety of symptoms and problems. Needless to say, the spectrum of pathology I encountered in this sub-Saharan clinical setting was vastly different from what I am used to in Britain. I saw diseases such as malaria, TB, gastroenteritis, intestinal helminths, typhoid, leprosy, snake bites, tetanus, meningitis and HIV/AIDS. I also saw conditions precipitated by the climate and culture of the area, such as bladder stones in children, malnutrition, and the effects of so called 'traditional' medicine, such as female circumcision. However I did also see a range of more familiar medicine, such as asthma, heart failure, diabetes mellitus and gastro-oesophageal reflux disease. I was able to assess patients on my own, and make decisions as to treatment choices with the help of more experienced doctors. This was particularly challenging as I was working with such limited resources. This ranged from being unable to prescribe oxygen for a child in acute respiratory distress, to seeing major operations performed under local anaesthetic.
Patients who were admitted as inpatients were provided with a bed fitted with a mosquito net, and one set of clean sheets for their entire stay. I was constantly amazed and impressed by the personal care of each patient provided for by their families.Often a patient would have a member of the family take residence on a mat on the floor by their beds for the duration of their stay. Once I saw a lady on her relative's bed, supporting her so that she would not have to lie flat and suffer the effects of orthopnoea due to heart failure. This was just one example of the many ways in which the practice of medicine differed between this country and the UK.
Many of the challenges I faced had to do with working in a cross cultural environment. For example, patients often presented at a far later stage in a disease process than they would in the UK. This was partly due to the inability to spend time and money on trips to the hospital, partly due to the belief that illness was 'the will of Allah', partly because traditional doctors would actively discourage the use of the hospital. This was a frustrating aspect of the work; I had to constantly remind myself that these attitudes and beliefs were the product of a culture I was not familiar with, could only observe, and was not to judge. Another example is the way some patients are limited in their access to facilities at the hospital because of their need to get permission from a husband, or community leader, or because they could not afford the time or money to come sooner. The obvious destruction caused by so-called 'traditional' medicine was heart-breaking.
Added to this was the challenge of working through a translator, usually a nurse, who was to translate my French into whichever of the local languages the patient spoke. I would say my medical French has greatly improved as a result! As time went on I was able to pick up on some useful phrases in the predominant language, Hausa. Soon I was confident enough to ask 'Aqwai ame?' – 'Have you been vomiting?', or to tell the patient 'Bouda baki' – 'Open your mouth'.
Living and working amongst the long term missionaries working on the compound or in the hospital opened my eyes to the real sacrifice that such a life involves. Not just the obvious challenge of the climate or the food, but also the frustrations associated with seeking to demonstrate the love of Christ across huge cultural divides. Through all this however, I also saw and rejoiced in the way brothers and sisters in Christ were united across so many divides; of age, culture, Christian background. It made me realise just how much we have to look forward to as the community of God's people in the New Creation, and what an awesome God we serve who has destroyed the dividing wall of hostility and made us all equal in Him.
The day would start with daily devotions from the Bible, and prayer for the work of the day, at 6.45am. I would try to attend the English speaking meeting held by the missionaries living on site, who met each morning, whilst the ward arranged their own meeting in Hausa. 7.30am saw the start of the ward round. At first I would attend the patients in the wake of the doctor whom I was following for the week, be that for adults, children or surgical patients. After a time I was given ownership of my own patients, and was to round on those whom I had admitted, in order to follow up on management plans I had initiated.
Morning clinic would begin as soon as the inpatient ward round had finished. Patients would queue up outside the hospital from the early hours of the morning, and would wait all day to be seen by a doctor. The clinic rooms would often be overwhelmingly busy. I shared a clinic room with a long term doctor from France, who was always available to ask questions. The result was a quite public consultation; patients would give me their histories through a translator and in the hearing of three or four other patients in the room who were waiting to be seen. A far cry from the strict confidentiality rules of the West!
At lunchtime the hospital would empty for around 2 hours, as the whole country took its siesta. After lunch I would go along to the ward to review my patients; to check blood results, order any investigations, assess progress as necessary. Meanwhile the OPD waiting room would be filling again with patients for the afternoon clinic. Usually we would have finished by 6pm, and I would be free to return to my house on the hospital compound.
For those evenings in which I was on call however, my day would be far from over. The nurses in the ER would have my number to call in the event of any patients who arrived after 6pm. I came to dread the sound of the phone ringing, and I kept my hospital's treatment protocol and Oxford Handbook very handy. I was grateful for the availability of the long term doctors, whom I could call to check I had started a reasonable management plan. A few times I was called in the dead of the night to attend to patients, and I will never forget the awful feeling of trepidation as I made my way to the hospital by the light of my torch (in case of snakes), and prayed that the patients would not be beyond my ability to assess. Fortunately there was never a patient I was called to in the night that was too ill to wait for further advice in the morning.
I was also scheduled for weekend on calls, which were much harder than a regular weekday, as I was to look after the medical side of the hospital alone. Again, I could always phone for advice, but it did feel like a big responsibility. I have no doubt that I learnt a lot of useful house officer skills during this time, including the recognition of being out of my depth and in need of some back up.
All in all, I feel that I learned more than I hoped I would, about cross cultural mission, about medicine, about the true gospel of grace. Although there were many challenges, there were also some real joys. It was brilliant to have the chance to work alongside the staff at the hospital and see a different style of medicine. The recovery of some seriously ill patients, seemingly in spite of circumstances was also a thrill. Finally, the opportunity to see what life is like as a Christian doctor living and working in a developing country was enlightening; I would seriously consider dedicating some time working abroad in the future; but perhaps when I am a bit more useful!