There is so much to say about the hospital where I’m working that I keep feeling too intimidated to write about it, and as a result fall more and more behind. A vicious cycle.
With every passing day and with every longing for certain modern conveniences, I see how incredibly spoiled we are in the US, how high our expectations are. This observation extends much beyond the scope of health care, but I’m going to focus on this first. Take, for example, basic sanitation. If you go into any major hospital in the US, there are going to be signs for Handwashing saves lives! Without a doubt, the handwashing crusade is important, and I would personally be horrified if my doctor even touched my face without washing his/her hands first. But in the hospital where I work in Tanzania, and at every other hospital I’ve been to here, there isn’t even running water. There are sinks, yes, but they’re dry, and I sometimes wonder why they even exist. Decoration? To give an impression of cleanliness? Instead, they use a bucket system where a stand holds a water-filled bucket with a small tap (like a water cooler), and there is a pail underneath the tap to catch the run off. The bottle of soap kept next to the bucket is usually diluted and frustratingly watery. Even with this, I almost never see any of the providers wash their hands while they examine the patients. And there are certainly no gloves.
And what about the doctor-patient relationship, the good bedside manner, that is the topic of so many magazine columns and form the buzzwords of medical education in the US? While I can’t describe the verbal exchanges with blazing clarity because of my ineptitude in Swahili, I can note that if an American were to seek care here, s/he wouldn’t last a half hour before erupting in a fiery rage over the often day-long wait time for a 3 minute visit with the doctor who does not hesitate to pick up her cell phone and have a chat in the middle of it.
Patient privacy is also high on the priority list for Americans, what with HIPAA and patients suing for reasons like exposure that they even sought care in the first place. Here, doctor visits and counseling sessions are done with the door wide open with other patients waiting in clusters outside the rooms. On Friday, there were a total of 12 patients in the room while I was trying frantically to keep them straight. As one patient is being wrapped up, the doctor sometimes tells him/her the full name of the next patient to call out when s/he goes back to the waiting room. Patients watch me as I’m working on other patient files right in front of them. Keep in mind that I work at a clinic that exclusively treats HIV+ patients. What confuses me further is the accompanying stigma associated with HIV/AIDS — why, then, is there lack of any attempt at guarding patient privacy? I know for a fact that patients do mind; I’m told that if they see someone they know, they make a run for it. One patient did her visit through a window because she refused to enter the hospital and let the people in the waiting areas see her and consequently know her status. Yet there seems to be no movement towards greater privacy and I have heard no real complaints from either the provider or patient side. Perhaps people have come to unhappily accept it.
On the other hand, HIV/AIDS care here is free and highly organized. The only cost patients must pay are transportation (which is major barrier to followup) and time. To be honest, I don’t know much about HIV/AIDS care in the US besides the fact that it’s expensive so I can’t compare specifics, but the care that I see in my hospital is comprehensive and integrated. In one day, patients will be group educated in nutrition/importance of ARV’s/importance of disclosure to relatives/etc, individually counseled on safe sex*/family planning/health maintenance, seen by a doctor, undergo any lab tests, and pick up their drugs. There are three blocks of patients a day and they move in a circular fashion around the hospital because the rooms they visit are sequential in terms of the services they receive. The documentation forms are standardized nationally; patients carry a CTC-1 form on their person that entitles them to free treatment regardless of which hospital or dispensary they go to, and the health center keeps a CTC-2 form (among other documentation) that records their health status and ARV regimen. If patients miss their scheduled appointments, they are tracked by health workers who determine the reason for their absence and counsel them to come back. I saw the form the trackers use — reasons include, but are not limited to: died, lack of transportation, not HIV+ (e.g. because they believe they were cured by religion).
To make a sweeping conclusion, let’s just emphasize the importance of traveling here. Not just for cultural intelligence and a more holistic view of how the world really works, but even in health care alone, there is much to be learned from any country, not just ones that are seen to be highly technologically advanced. Countries with fewer resources learn to be more resourceful and often yield impressive results with very little.
* The counselor I worked with for a little bit told me that they use a wooden penis model to demonstrate proper condom use. When I asked her to see it because I hadn’t seen one before, she asked me, “you don’t have a boyfriend?” and laughed. I told her I just hadn’t seen a wooden model because we use ndizi (bananas) in the US. I’m pretty sure the model is made from ebony — high quality stuff — and it comes with its own stand. After a minute or two, the counselor announced that she had to put it away because it would scare the children.