From Elective Reviews - Zimbabwe - Mutare Provincial Hospital - an Experience of Paediatrics in a Public Hospital
Zimbabwe is a wonderful country which unfortunately has experienced many difficulties economically, politically and agriculturally; all of which have had a knock on effect to its public healthcare system. I was set to spend my time in Mutare, the 3rd largest city in the country at the Provincial Hospital, which receives patients directly, but also from district hospitals and local clinics.
Having arrived in Zimabwe, the first thing one must do if you are taking your elective here is to get through the mountain of paperwork to do so. Having obtained a tourist visa on entry there are a few things you must do to get a study permit. I had originally registered with the University of Zimbabwe medical school whilst in England (and paid them US$400) and I had to collect my stamped letter of authorisation; then go and register with the Medical and Dental Practitioners Council of Zimbabwe (like the GMC, and paid them US$30). I could then finally head to the immigration office.
After a treasure hunt style to find the unsignposted immigration office which is cleverly hidden up some stairs in a shopping mall, I could then apply for the permit. What I hadn't been told previously (the university said it would be very simple, cost US$80 and their letter was enough) was that you have to write a letter of application for a study permit, obtain 2 authorised photos from the commissioner of the oaths (more money!), complete their long application form, pay US$200 and then wait a few days whilst they process your application. Whilst slightly frustrating; finally I got my permit and could head to Mutare.
On arrival at the hospital, I had to go and register with the Medical Superintendent, Dr Masanga- who fortunately is also a paediatrician. After reading and signing the official secrets act and being told in no uncertain terms that I was not to take photographs (I later requested permission to take photos for this report which was granted on the condition I did not photograph buildings or unhappy patients).
My first day started as all days as a medical student in hospital do: with a ward round. This was a good opportunity for me to absorb the not so alien environment I found myself in. There are several paediatric wards, an acute ward with 8 beds (contains the nurses table so they are close by), a general ward containing 15 beds, a burns ward containing 20 beds, a baby ward with 4 cots, a malnourishment ward with 5 beds and then the neonatal unit with 4 incubators, 1 resusitaire and wooden trays which could take upwards of 20 babies.
By the end of that first ward round I was feeling a little overwhelmed; there were many familiar conditions; low birth weight and premature infants, bronchiolitis, neonatal sepsis etc. But I had seen a presumed congenital rubella in a neonate with cataracts, severe hypoxic ischaemic encephalopathy (HIE) in many neonates whom were born either in rural clinics or district hospitals where there were no obstetricians, cerebral malaria, and severely marasmic children to name but a few.
The thing I found hardest to adjust to was the lack of resources for these children to be cared for. Everything was clean and there were an abundance of nurses, but often no soap for handwashing (we had plenty of typhoid admissions), no toilet paper in the bathroom, there could be up to 3 children per bed, incubators (there were 4) had up to 4 babies in them. On my second morning, due to the high number of neonates with HIE having seizures and requiring phenobarbital; the hospital had run out. So whilst doing the rounds there seemed to be baby after baby just seizing in front of us and all we could do was watch. We asked the parents if we wrote a prescription for the drug could they buy it (It would have been about US$2 for a vial and they could have shared it), but they just couldn't afford it. Unemployment had just tipped 85% when I left Zimbabwe, and people were living in absolute poverty. Although I came to accept that this was the way things were, there was one particular patient who sticks in my mind. A 13 year old girl came into clinic (one of the consultants was a specialist in cardiology) she had suspected mitral regurgitation, was severely short of breath and had a grossly distended abdomen. She had severe mitral regurgitation with hepatomegaly to below her umbilicus and severe pulmonary oedema. She had been under the care of the consultant for many years. Apart from pharmacologically treating her condition, there are not the facilities (even if she was referred to the capital city) for her to have the valve replaced and live a fulfilling life. As the eldest child her parents had only been able to afford to send her to school, her other siblings were not educated. Her mother told me her daughter was going to get a good job as she was bright and doing well in school, and that it would mean her family could have a better life. As we admitted her from clinic to the ward, the consultant told me he wasn't expecting her to survive the next few days. Amazingly she did recover and when we saw her in clinic (my last week in Mutare) she was doing much better. But when I questioned my consultant about her life expectancy, he remarked that she was unlikely to survive to see 20. This patient played on my mind an awful lot whilst away, and also since I have returned. Should she have been in the UK, she would never have reached the point at which we saw her in clinic, she would have had a valve replacement and would be able to continue living her life. Her parents had invested all their money and expectation in this child whom was not likely to fulfil their wishes, let alone have the opportunity to live.
Those who can afford private healthcare do so, and there are many facilities which aren't even available in Zimbabwe. For example, if you need open heart surgery you have to go to India or South Africa. Healthcare in Zimbabwe used to be free, but with the economic difficulties faced, there are now charges; which can be set by the individual hospitals. This has massively limited access to healthcare. Children under 5 are treated for free, but many parents do not know this. They would have to pay to go to the local clinic so don't turn up to the hospital until their child is extremely unwell.
Whilst it was emotionally challenging at times, my elective provided a good opportunity for me to develop confidence in my abilities as a clinician. At the end of my second week the 2 junior doctors left, leaving myself and consultants. 2 days a week I had the opportunity to do the ward round alone with a nurse, before the consultant came in and we did another quick round. The fact that parents didn't bring their children to hospital until they were really sick, or that they were referred from the whole province meant I saw some really unusual clinical conditions, to include prune belly syndrome, gastroschisis, sacrococcygeal teratoma, DIC in neonate and epidermolysis bullosa. Furthermore I got to develop clinical skills, performing neonatal and paediatric lumbar punctures, doing paediatric bloods and cannulas and interpreting paediatric images. The 2 consultants I spent my time with taught me so much, not only about the medicine, but emotional resilience. They shared with me the heart ache when patients died, taking the pleasure in the small victories of each patient and I developed humility being able to work alongside them in what can only be described as one of the best careers ever.
I would like to thank the Beit Trust, Richard De Metz and the Enid Linder Foundation for their generous bursaries towards my elective which made the trip possible.