Blogging Mozambique

Post-call - Dr. Ryan Meili - July 2010

This last week we were on call. With all of the doctors away at an annual meeting in the provincial capital of Inhambane, Mahli and I found ourselves the only physicians for 230,000 people. Imagine one family doctor and one pediatric resident on call for a district with the population of Saskatoon!

Given such a large area, and the fact that for many reasons, including knowledge, traditional beliefs and transportation, people often present later than we would expect them to, we found ourselves dealing with a great variety of conditions. These  included: HIV and pneumonia, pyelonephritis, 3rd degree burns, fall from the first story of a building, dog bites, machete mishaps, countless cases of malaria, simple and complicated births, newborn resuscitation, delirium tremens, cardiac failure, HIV and encephalitis, suppurative bacterial thyroiditis (a very rare condition, only 100 cases are described in the medical literature), Marasmus, Kwashiorkor, severe anemia (in most patients, some as low as 20mg/L, normal being >120), acute teenage psychosis, acute renal failure, strangulated hernia,  HIV and gastroenteritis, a mini-outbreak of meningitis, diabetes insipidus, Burkitt's lymphoma, HIV and tuberculosis, liver failure with massive ascites, Kawasaki disease, cervical adenitis, seizures, abdominal TB, Ludwig's angina, a ruptured spleen, syphilis, HIV and pelvic abscesses, unexplained unilateral edema of the entire body, fever of unknown origin, bronchiectasis, HIV and Kaposi's Sarcoma, and intractable hiccups.

It was of course an unusual situation to have two physicians on call for this period. Usually it's less. When we aren't around there are only two doctors in total for the district. Both recent graduates of medical school in Maputo, and both very capable clinicians, they are torn in many directions. They not only work in the hospital, but are also constantly required to represent the health sector at official meetings throughout the district, collect and report on statistics, and receive continuing education, sometime for days at a time. This leaves the hospital primarily in the hands of nurses and medical tecnicos. Unlike in Canada, nurses here have only very basic training, limited to practical skills with little clinical understanding. Tecnicos have more training and operate independently. They admit patients to hospital, follow them as inpatients, and manage much of the outpatient care of both HIV positive patients and the general public. They tend to be very good at managing the more frequently seen illnesses but struggle with anything complicated or out of the ordinary.  This system, in which basic and mid-level trained health workers provide the bulk of care, was designed to meet the ongoing health human resource shortage in a country with unlimited health needs and limited resources for training and employment. To some degree it succeeds in meeting the needs, but as you would expect, the shortcomings are many.

The other level of health care delivery in the country is that of the traditional healers known as curandeiros. Only 40% of Mozambicans can access western medicine at all. The remaining 60% can count only on the services of the curandeiros. At times,  the curandeiros are the bane of our existence. Patients arrive late with serious diseases because they sought traditional help first, or they arrive suffering from the toxic effects of plant-based medications. The families of patients with severe but treatable conditions often get impatient and take them out of hospital to seek traditional care, risking death by interrupting essential medical treatment for illnesses like meningitis. On the other hand, the curandeiros are the main providers of health care in the country. Even among the 40% who can access hospital-based care, the vast majority will also consult a curandeiro.  In recognition of this, the Mozambican Ministry of Health has created MeTraMo, Médicos Tradicionais de Mozambique, a national association of traditional doctors. They meet regularly throughout the country to share best practices, including the use of safe materials in traditional practices (avoidance of unsterilized needles or blades) and recognition of signs of illnesses such as malaria that need to be directed to the hospital. The Ministry has been very bold in recognizing that the way to improve health in Mozambique is to work with the best of the existing beliefs rather than try to dismiss them all as negative.

Two years ago James Sylvestre, a friend of mine from Buffalo River Dene Nation in NorthWest Saskatchewan, came to Massinga. Every year he and his family welcome the students from Making the Links and he hosts them in his sweat lodge. He also welcomed Mozambican teaching students who visited in 2007. When he came to Mozambique he met with a number of traditional healers and addressed a meeting of MeTraMo. This was a fascinating exchange as there were a large number of similarities between traditional ceremonies, hunting and medicine and more between the Dene culture of Northern Saskatchewan and that of the Matswa people of Inhambane.  It was also very interesting for the students and doctors to get a better understanding of the beliefs related to health and the approach of the curandeiros to medical problems. This video, documents his visit and the Making the Links program.

Back at the hospital, recent changes have us optimistic for the future. I mentioned in an earlier blog the opening of the operating theatre and the assignment of a tecnico with special training in surgery and two with training in anaesthesia. This week we received two new doctors, young women recently graduated from medical school. With the transfer away of one of the existing doctors, there will now be three full-time physicians. There is also a move away from requiring the involvement of the medical staff in the political and administrative side of district health, meaning they can spend more of their time seeing patients. Perhaps most encouraging is the presence of Dr Stélio, a young physician entering his second year of service in Massinga. He is extremely bright, committed and idealistic. This coming week we will work on mission statements for the hospital and its different departments. This is the first step in developing a system to improve performance at the hospital; by identifying the goals of each department we can then implement a means of analyzing and addressing the gaps in service. This is very exciting for me, as after many years of visiting Massinga hospital it seems there is finally the appetite for this kind of system change. It's also frustrating because our time here is so short, and we will miss both accompanying the process and witnessing the resulting improvements in patient care. The feeling upon leaving the hospital is the same as after any intense call shift, a combination of exhaustion and exhiliration, satisfied to have contributed but, as always, wondering if there's more we could have done.

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