This week take a medical turn as the Diploma in Tropical Medicine and Hygiene started. Predictably, the content for this week is more medical. Sorry and i will try and keep it balanced in future!

The course i am on gives a chance to “take call”, as one of the (American) course teachers calls it. "Taking Call" can be summed up as observing the medical, or peadiatric, patients that come into the hospital during the evening. From this experience I want to talk about two things, firstly some general differences, and secondly the experience of one patient in particular. The individual experience, for me, epitomizes some strong arguments regarding health policies.

By the time I had left, at just after 10pm, there were 13 patients admitted that day. Apparently this figure varies between 10 and 25. More than anything I was amazed by how similarly the system functions compared with back home. A name appears on a list, and then the most junior member of the team sees the patient, suggests a management plan, and this is reviewed by the registrar (or resident). Much like back home.

There are clearly differences  in the environment, resources and patients. The wards are over-occupied, with patients in the corridor. The doctor has fewer investigations and treatments to choose from. At one point the wards were plunged into darkness for several minutes with a power cut, before the generators came back online. The patients are, from what I have seen, generally referrals from external hospitals who have made their own way with a view to specific investigations or treatments.

The general atmosphere struck me as different. In the UK an acute take, to describe an extreme, the registrar is fielding calls from multiple teams whilst also running a crash call. This take seemed a very quiet and sedate evening, the registrar called his time in just after ten, and to be honest there didn’t seem much to be done after that.

The patient I wanted to focus on was a 24 year old man who was admitted with massive ascites. He had been transferred from another hospital as he had been treated for 2 weeks with anti-TB treatment and there hadn’t been much improvement.

To start with this is a young Masai man, who supports a young family by tending to his cattle. He is essentially one of the young men and women lifeblood of a productive and developing nation. Each day and hour he can’t work means that his children are less likely to get to school and so on. And surely where there is one there are more, there are scores of mid 20 year old men who turn up at hospital to receive treatment for a problem which leaves them unable to work, and worse endangers their life.

Now, bearing this in mind, two things happen.

Firstly, the intern clerking him makes an excellent management plan, which is duly agreed by the resident. He needs to be checked for Hep B and Schistosomiasis, and he needs a diagnostic tap of his ascites, along with several other routine tests. He writes the forms, gives them to the patient and says, now you have to go and pay. I never saw the end of what happened to know if they did or did not manage to pay, but the patient – who I remind you is from over a days travel away – and his two young friends sat in a huddle to work out what they could do. 

Secondly, the patient has had two weeks of anti-TB treatment. The intern suggests that this should continue. However, he does not have the drugs. To my surprise the intern says: “We don’t stock anti-TB drugs here (here being the tertiary referral centre for medicine for a region of 11 million people). The patient has to go into town to the other local hospital to the TB treatment centre to pick them up”.

This patient highlights two big issues for me.

1. User fees – As I said earlier, people this age matter to the nation. The fact that this young man is asked to pay again and again for investigations and treatment are barriers for him and people like him accessing care. For me this has been clear for a while. While I was on elective in Sierra Leone I saw how the change affected people (http://www.msf.org.uk/UploadedFiles/Kambia_handover_abstract_FINAL_200806114404.pdf). Again here, for the sake of the cost of a few investigations and some medications, the future productivity of a working age man or woman could be lost!? That’s year on year of revenue for a country! Taking a personal view, is it right that a young mans loses the chance to put his family through school because he contracted an infectious disease?

2. Vertical Programmes at the Expense of the Health System – The TB coordinator for the region hands out free TB medication to those in whom TB is suspected. Unfortunately they are not in the tertiary referral centre for the region, they are based elsewhere. Why? Because TB treatment, along with HIV and Malaria are programmes funded externally by big donors and so are managed separately to the health care service as a whole. As a result you get cases like this, where systems have evolved separately to the detriment of our patient. Furthermore, if there is an HIV+ve patient on the ward, for the administrative cost of 40 pence (70 cents) they then receive free treatment for most major conditions. Great. But what about the diabetic next to them? Or the young patient with an Hb of 4 from their H.pylori ulcer? They don’t have access to a insulin, an gastroscopy unless they can pay their way. Its great that these vertical programmes have been shown to make such a difference, but what happens when Bill Gates money dries up. These countries are left with the hospitals and systems that have been trying to evolve in the background. Those that are unable to deal with the burden of non-communicable disease and huge variety of clinical problems that walk through their door. However, I am sure that the shiny TB clinic downtown will still look great.

Finally, my apologies. It has all turned into a rant which is an unproductive focus for a blog. I will try and make amends in the future. And I’ll finish with story.

I met the son of a Tory MP and a doctor. He was just about to start medical school herself. I said great, did you take a gap year? No, I really wanted to but it was too expensive. But what do you mean I said? Well, if I started next year I would have to pay tuition fees…

So the son of a Tory MP and Doctor is put of higher education because of fees… Firstly there is an irony in there somewhere. And secondly, if his family can’t afford it who will be able to!