From Elective Reviews - Zimbabwe - Mpilo Central Hospital, Zimbabwe 2014
My medical elective at Mpilo Central Hospital in Bulawayo, Zimbabwe was a truly phenomenal experience. Before starting my elective, I had mentally tried to prepare myself for what to expect, knowing too well that Mpilo hospital was a poor government hospital, which served a large and impoverished community.
My first day began at 0800 in the gynaecological theatre. As I walked into the theatre area the corridor was lined with about 20 women patients waiting to be prepped for their operations. The first task of the day was to find scrubs. I quickly learnt to accept whatever size scrubs there was and be grateful for finding scrubs available at all.
Walking into the theatre rooms at Mpilo was like taking a step back in time to the 1980s. The outdated medical equipment, from the faded dim operating lights to the little fan heater in the corner of the room which acted as the only source of heating in the theatre, despite it being mid winter.
However, my first true encounter of how different health care and practice is in the UK compared to the developing world was when I observed an evacuation of retained products of contraception (ERPC) following a miscarriage at 18 weeks gestation. In England, from my experience, this is usually a very clinical solemn quiet procedure where the patient is supported throughout the different stages of the procedure. However, the situation at Mpilo hospital was a stark contrast. The gynaecologist, whom I was shadowing, was expected to perform five ERPCs within one hour if he was to try stay on top of the workload. In credit to this doctor, he worked tirelessly and extremely efficiently.
However, the whole scenario appeared to me as if the patients where all on one huge conveyor belt, one ERPC after the other. Besides the staff introducing themselves, no one really talked/gave any support to the patients. Medical staff kept coming in and out of the theatre to get various surgical instruments or to enquire about other ill patients on the ward. In my view it all seemed so chaotic and I felt deeply for the patient and how emotional she might be feeling in this situation. In hindsight, I can see that the staff were not willingly being negligent in their psychological and emotional support for the patient, but rather that with such a great shortage of staff, none could be spared for this job.
That first day is imprinted in my mind. Later in theatre, I went on to observe my first Radical Wertheim's hysterectomy of a lady of 33 years old. She was HIV positive with stage IIB invasive squamous carcinoma of the cervix (metastases to uterus, fallopian tubes and lymph nodes). She presented with a distended abdomen (uterus size about 28 week old pregnancy), lower abdominal pain, intermenstrual bleeding and vaginal discharge. She is married to a 70-year-old man and has 2 children also HIV positive. This case was one of 4 such cases I saw during my elective, all of young women with Stage IIB cervical carcinoma and HIV positive.
Despite hearing such dismal stories in the news and from peers it all became much more real and heart-breaking when face-to-face with the reality. There were many issues in this woman's case, which surprised me and made me ponder. For example, how young she was to have such extensive cervical cancer as well as HIV, the age difference between her and her spouse, if any precautions had been taken to protect her children from contracting HIV in pregnancy/pre/post-natally?
Despite cervical cancer being the primary cause of all cancer deaths in Zimbabwe,1 this country, unlike the United Kingdom, does not yet have a national cervical screening program for cervical cancer, neither is the Human Papilloma Virus (HPV) vaccine part of the childhood vaccination programme. These facts and the high HIV prevalence (15% of adults) further adds to morbidity and mortality in Zimbabwe.2
I enquired from gynaecologists and paediatricians in the hospital about Mother-to-Child HIV Transmission rates as well as researching the topic myself. In Zimbabwe the HIV transmission from mother-child accounts for the second highest number of new HIV infections following heterosexual intercourse. Furthermore, in Zimbabwe, every year 14,600 children are infected with HIV.3 There are numerous reasons for this such as limited accessibility to treatment and to clinics, many women fail to attend follow-up appointments, the stigma still associated with HIV and continued breastfeeding in HIV positive mothers.3
The more time I spent at Mpilo hospital, the more I realised the vast chasm between western medicine and medicine in the low-income countries. In my opinion, in western medicine we carry out the most appropriate, up-to-date and effective investigations and treatments, rightly with the patient's well-being and health being of more importance than the cost of these interventions.
However, in Zimbabwe this is was not the case. The sheer poverty of Mpilo hospital and the patients was apparent each and every day! In a hospital where patients are required to bring their own bedding, where simple medical paraphernalia like gloves, urine dipsticks, needles and bandages are scarce and where advanced medical equipment like MRI and PET scanners or key-hole surgery are just a fanciful dream, the world here is incomparably different!
It was not till my elective that I truly appreciated how amazingly privileged we are in the UK to have the NHS healthcare system. Here it is a right for a person to receive first class free, evidence based, patient-centred care regardless of their ethnicity or economic status!
The majority, if not all, the patients at Mpilo could not afford medical aid. So whatever treatment they need, the patients were required to pay themselves. The scary reality of this is where a patient needs an emergency Caesarean section but does not have the means to pay, there is no government aid or free emergency subsistence, so her only option is to beg for or otherwise procure the money or risk death trying a vaginal delivery at home! Due to financial constraints the majority of women admitted to the obstetric unit, had only ever had one antenatal appointment. This meant I saw many women presenting with advanced obstetric complications, which sadly some of which could have been avoided.
The stark contrast between the theatre and Caesarean sections performed at Mpilo compared to Hull Royal Infirmary was almost unbelievable. Due to lack of resources; sterile gloves and sterile drapes are simply not available so non-sterile gloves and rewashed drapes are used instead, all C-sections are performed under general anaesthetic as the hospital has no anaesthetists specialised to perform epidural or spinal anaesthesia and wound dressings consisted of a swab and two strands of surgical tape. Undoubtedly, the lack of sterile operating conditions and poor post-op wound care contributed greatly to each day having 3 to 4 patients on the ward with septic suture lines following a caesarean section. Nonetheless the obstetricians worked with such dexterity and skill when operating that, in my view, they really did all they could in the situation pertaining!
Being in such an environment invariably pushed me to think out the box, to rely greatly on my own somewhat limited clinical knowledge and expertise. The experience of practicing Obstetrics and Gynaecology in Mpilo hospital was phenomenal. The hospital delivers on average thirty babies a day, so I was fortunate to see and assist with countless normal vaginal deliveries and Caesarean sections.
I also was privileged to see more rare obstetric complications such as uterine rupture, placenta previa, placental abruption, eclampsia and puerperal psychosis. In addition, there were many cases of women admitted with obstructed labour and so I also learnt how to assess for this and how to detect caput and moulding of the fetal skull.
In conclusion, I would like to say a huge thank you to Beit Trust for awarding me the Beit Trust Bursary, which helped to fund part of my elective in Zimbabwe. I cannot express how greatly I have enjoyed my time in Zimbabwe. My elective has also re-affirmed my conviction to work in healthcare in the developing world in the future. It truly was an eye-opening experience. It helped me gain a real perspective of the materialistic world we live in and to appreciate and be grateful for the many blessings God has given to me.
1. WHO supports introduction of HPV vaccine in Zimbabwe.[Online].2012.[accessed 2014 Oct 06];Available from URL: http://www.afro.who.int/en/zimbabwe/press-materials/item/6992-who-supports-introduction-of-hpv-vaccine-in-zimbabwe.html
2. Zimbabwe Statistics.[Online].2013.[accessed 2014 Oct 06];Available from URL: http://www.unicef.org/infobycountry/zimbabwe_statistics.html
3. HIV & AIDS in Zimbabwe.[Online].2014.[accessed 2014 Oct 06];Available from URL: http://www.avert.org/hiv-aids-zimbabwe.htm