Every morning around 7 a mass of people make their way to a ramshackle rectangular single story building to wait in waiting areas in the open but under a roof. The clinic has 3 offices, a dispensary, 3 wards - one for children to be observed, one for women, (?where men go i havent worked out), and one for women in labour. There are 2 consulting rooms, both of which are so small that the patient has to clamber around the doctor to reach the examination couch. UK infection control nurses would have a fit over both of these rooms. Then there is the pharmacy store- which is the only room to have air conditioning - so it is visited very frequently for consultation with the pharmacy technician, and a roomy and neat lab - ruled by a very neat and tidy lab technician who glories in the name of Troglet.
This lab is an exception, as the other rooms are grotty, and not too clean, with paperwork, supplies of syringes, needles, malaria testing gear, instruments, iv fluids etc. all lying in a random mess. The walls go up to about 8 foot high but are mostly open at the top which doesnt do a lot to help confidentiality, and this is a Christian country in which we have to ask about sexually transmitted infections, and HIV in most consultations. Probably it doesnt matter as the doors tend to be left open anyway, and the next patient will tend to stand right by the doorway, so any attempt to preserve secrecy would be doomed to fail.
Fortunately the light in the daytime in Zambia is strong as very few lights in the building are working- strangely these seem to all be in the offices! Even the offices cannot be protected from the other main logistical problem which is that the water tank which is up on a platform above the clinic, is leaking badly, and the budget of the clinic is not sufficient to pay for a replacement.
People have a card with a number on to identify them, and this number then allows the right medical file to be found on several rows of shelving. Often patients forget their number and lose the card, so they can end up with several different copies of medical records. The obvious alternative would be to file by name, but surnames are mostly Banda or Phiri and with no records of date of birth - the confusion between different Thomas Banda would be a huge problem. Also patients like the ability to lose their records as it allows them to get a second opinion every 3 months when the new doctor arrives.
As one might expect - every day brings a few patients who are much sicker than is common in the UK. Patients arrive looking very unwell with Malaria and are simply given a few tablets of Co-artem and are sent home. In my first couple of days work i have also seen a really nasty tonsillar abcess (it was really gratifying to see how much good a big dose of Penicillin in his bum did), a child who was generally looking ill with an infection on his scalp - but sadly whose HIV test was positive, an old lady with a stroke, a very old lady with acute heart failure and probably a cancer in her abdomen, and a man writhing in agony with kidney stones.
Which leads on to the next big problem with the clinic, which is lack of drugs and dressings. There are barely any of the latter, and in a country full of dirt and insects that is not great! As far as drugs are concerned, there are plenty of HIV drugs and we seem to be ok for Malaria, and we have Aspirin -(useful for the stroke), but otherwise very few, and nothing that could be expected to treat renal colic for example,or anything very helpful for palliative care. I suspect that there is a logic to the extremely limited drug supply, which is that the culture fully embraces polypharmacy (just like the uk! ) and the general attitude is 1 drug good - 4 drugs better! so some nurses will prescribe for dizziness for example - panadol, an antihistamine, valium/diazepam, and multivitamins. So perhaps the idea is to restrict the supply, then we can restrict the harm! Perhaps we should adopt this principle in the UK?
So, should one try and do something about these issues, - or just put up with the deficiencies of the system, learn to accept them, and do the best i can with the tools available, and then go back to the UK having learned how to implement that passive strategy. We shall see how I manage.
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