From Elective Reviews - Zimbabwe - Mutare Provincial Hospital
I went on elective to Mutare Provincial Hospital in Manicaland eastern Zimbabwe with 2 fellow students from Imperial College London. Mutare is the third biggest city in Zimbabwe (after Harare and Bulawayo) and our hospital, being the biggest government hospital in western Zimbabwe, acted as a secondary referral centre and received patients from as far away as Masvingo whilst referring more complex cases to Harare. The hospital staff were extremely welcoming to us and went out of their way to make sure that we were happy and able to make the most of our attachment.
Of course any elective requires a certain amount of organisation and paperwork and ours was no exception. First we had to find a hospital in Zimbabwe who would take us on placement. It was difficult to contact many hospitals, most replies we received were positive, but saying that they would be unable to host us. Mutare was the first to accept and we are happy that they did. However we quickly saw the first obstacle away and soon we were arriving at Heathrow with our flights out (via Nairobi for a 12 hour stopover). We arrived in Harare in the middle of the night and breezed through customs and immigration on a tourist visa (we planned to apply for a study visa later). We got the last taxi in the airport and arrived and our first host's (who has asked to stay anonymous) house. For the next few days this would be our base to try and get all our paperwork sorted as at this point we only had got permission from the hospital. We were put in touch with Minette, another Beit student currently working at Parirenyatwa hospital, who advised us on all we needed to do. Firstly we had to register with the University of Zimbabwe Medical School as elective students for a fee of $600US and then register with the MDPCZ (Zimbabwe's version of the GMC) for $30US – foreign doctors pay $800 to register. With all the formalities in place we found cheap hire car ($35 a day with unlimited mileage) and headed off East with the added excitement of finding out we had all passed our medical finals!
On arrival our first host had arranged for us to stay the night with a friend of hers at his hotel. It was nice to have someone to help us to find our feet. We soon sorted out longer term accommodation with Ann Bruce at her guest house. Ann was well used to elective students and a fantastic host. On our first afternoon we headed over to the hospital to meet with the superintendent and human resources department. We only had one problem and that was that they had no records of us at all! An anxious hour followed until the superintendent could contact his predecessor who was able to confirm our authenticity. We pushed on with the last bit of admin which included signing the Zimbabwean Official Secrets Act! In this we promised that if any patients (who might be military or police) were to tell us state secrets when unwell we would keep them secret and that we would report anyone that might be plotting against the government -fortunately we never had to test our allegiance to the Zimbabwe government. We were given the opportunity to make our own timetables and to choose any specialties. I choose general medicine, general surgery (including paediatric surgery) and the casualty department.
As expected, medicine in Zimbabwe is quite a different concept to that in the UK. My first rotation was on general medicine, where I encountered a number of infectious disease patients with HIV and its complications, TB and malaria making up the majority of admissions. The wards were run by a registrar level doctor and a house officer. Whilst we were there, there was no consultant as he was unwell and receiving treatment in South Africa. Our day started at 9am with a ward round lasting 4 hours with the medical team and the nursing staff from the wards. Many of the patients had complex medical problems and with limited diagnostic facilities diagnosis was often difficult and many patients were clearly misdiagnosed. One of the biggest problems for Mutare was that although they had all the machines required for diagnostic testing including a well equipped pathology lab and an x-ray department, they lacked the basic consumables to make these work.
Blood tests were limited to full blood count, urea and CD4 count once a week. Tests could be sent into the private laboratory in town, but the patients would have to pay for this and they rarely had the means. Even once you had a proven diagnosis treatment would be limited; HIV, TB and malaria medications were always in good supply but other treatments were lacking. Cryptococcus meningitis is a common serious HIV complication in Zimbabwe (which is rarely seen in the UK) and 3 of the 4 lumbar punctures I performed grew this fungus, but they did not have access to the correct medicine (as it is very expensive) so a diagnosis of cryptococcosis was managed with insufficient treatment and unfortunately had very poor outcomes. It was shocking to see the number of patients that died in hospital in Zimbabwe and on a number of occasions we would find that a patient we had seen at the start of our ward round had passed away by the end of it. The staff were well trained with the nursing staff being rather firmer on the patients than in the UK. Medical school and junior doctor training in Zimbabwe has a similar structure to that in the UK with the local house officers often showing us up particularly in infectious disease and in their practical skills, with medical students expected to be competent in areas that are usually postgraduate in the UK. We were able to benefit from this training and and it was on the Mutare medical wards that I performed my first lumbar punctures and a pleurodesis, a procedure to stick the two layers of lung pleura together and prevent pneumothorax.
General surgery was well run with two experienced consultant surgeons at the hospital. The operating theatre was well equipped with donated equipment and they were able to perform many complex surgeries. I was most impressed by the versatility of the surgeons, in the UK a true general surgeon is rare but in Zimbabwe an operating list might include an appendicectomy, resection of a liver lobe and simple neurosurgery. Cancer operations were common with similar incidences of cancer to the UK, but patients would present with considerably advanced disease often due to the lack of primary care services to pick up on early symptoms. Many conditions we saw are unheard of in the UK, including leopard attack and snake bite! I had further opportunities to perform simple practical procedures such as draining an abscess.
The hospital's casualty department was shockingly run - emergency medicine is not a recognised specialty in Mutare with the general medical doctors covering A&E. Patients would present to the department and would not be triaged, if they were unstable when brought in by ambulance (little more than a modified pickup truck) then they would be taken to the resuscitation room. There was limited equipment available for resuscitation, only very basic airway devices and fluids were available. The only monitoring equipment and defibrillators were in ITU and theatres. With such little resources available the local doctors really have to exercise their basic clinical skills and judgment to reach an appropriate management plan. One women I saw a had come in with an acute asthma attack, we were able to give her salbutamol nebulisers (which her local hospital was unable to do due to power cuts) and reassess her after. UK protocols for asthma rely on being able accurately measure the disease with simple tools such as peak flow which weren't available and she was admitted to the ward for repeat assessment and more nebulisers. An interesting case was a women who had ingested rat poison, in the UK most rat poison are vitamin K antagonists which thin the blood and are similar to the anticoagulant warfarin. On talking to the local staff, it transpired that in Zimbabwe they use a completely different chemical (organophosphate based) that is only poisonous to humans in large quantities, I re-assessed her to look for signs of organophosphate toxicity of which there were none and sought advice from my seniors.
Mutare Provincial Hospital provided a highly educational and eye-opening experience into healthcare in Zimbabwe. It was great to be able work with the local doctors and nurses, sharing ourexperiences and expertise and sometimes just offering a fresh perspective to come together with management plans that would really help our patients. My 7 weeks in Mutare was enlightening and useful for my future career as a doctor.
In the few weeks we had outside of the hospital we made sure to see as much of the country as we could. Zimbabwe has a well organised and reasonably well funded national parks system where cheap accommodation was available. Some of the highlights included climbing mount Nyangani the highest mountain in Zimbabwe and seeing Mutarazi falls, the second highest waterfall in Africa. The people of Zimbabwe were often surprised to meet foreign tourists but were overwhelmingly welcoming. We always felt safe and took only a few more precautions than one would on any foreign holiday.
Zimbabwe is a fantastically beautiful country, it truly took my breathe away. It has left me so many fond memories and even some new friends. I would like to thank the generosity of the Beit Trust and its Trustees and all of the kind people we met during our stay for making my elective possible.
Dr Rupert Parker