Although we have struggled each year with the realities of
Ilula, this year it seems especially acute. The backdrop of this experience
with the learners and faculty is the extremely resource-poor hospital.
For example, medicines are not supplied by
the government as they should be. Or other supplies like lab reagents, the lack
of which idles essential machines and thus cannot provide the tests that could
guide our care if we had them.
We can
live with this and depend on our clinical acumen and our Tanzanian colleagues’
experience.
This accompanied by the
helplessness we feel when our patients die, sometimes because we do not know
the correct treatment and do not know the disease we are treating.
We name things as best we can and work from
there.
We sometimes do differ in therapies from our colleagues
too. In Ob, our learners have made the
diagnosis of pre-eclampsia a couple times and the doctors seem to be slow to
respond. This tries the physical
capacities of the two patients, mother and baby. The wazungu look on in pain, so aware of the
differences in approaches to care. We
are used to being so much more aggressive.
The choice sometimes comes down to precious resources at a full (US)
course of therapy or several partial courses.
Which approach helps more patients in this resource scarce
environment? We have only our biases to
support our opinions on this. It will
stay this way until resources are adequate.
There are advances here including a significant drop in child and
maternal mortality over the past half dozen years.
We have smart colleagues with local experience which
certainly trumps our intellect, knowledge and experience nearly every time. Well not every time. We have some pretty smart cookies with us,
faculty and learners.
But more disconcerting I think is a category of factors,
like under-nutrition, which I refer to as “the disease hiding in plain sight.” We see a tremendous disparity in things we
think are controllable in any setting.
The Ob suite is always clean, despite a half-dozen or more deliveries
per day. I am a little reluctant to cast
aspersions, since we know that the resources are so frustratingly low. Some of the wards are dirty. Yes, it is difficult to keep the chickens out
of the open ward. And some of the wards
were painted last year. This was a
donation by visiting group. Maybe the
dirty stains need to be covered by new paint now. Still, without cleaning, it will need more
paint soon. Does the lack of resources
excuse the dirt? Or perhaps the lack of
resources saps the pride from the staff and this has become the “best we can
do.”
And here we are. All
bright and shiny, here for a few weeks once a year. Who are we to criticize? We want to help and yet we must take great
care not to judge. So our existential
question is this: how?
The above is capped off by the importunate speech we heard
this morning. It was mostly in Swahili,
but several of us picked up on the words, “palliative care.” We asked for a summary in English.
The palliative care team is usually a chaplain as leader, a
nurse and a doctor. They go out about
once a week if everyone is available.
They dispense some medicines, write prescriptions and provide spiritual
as well as medical care, a truly holistic endeavor.
They have no funding.
And they have 850 patients in need, and simply too few staff to provide
the care.
Except as the charity of the staff can provide, that is. They did have some fairly regular support
from somewhere which has dwindled. There
is also the “poor patients’” fund, donations solicited from visitors. I
think it is a pittance.
I know the palliative care team could use cash, especially a
regular stream. They write prescriptions
but often are thwarted when the patient cannot afford the medicine anyway. Heart rending was the request for food and
clothes and, of course, medicine. Yes,
all of those do translate to money. And
I suppose there is no end to the need.
It is the starfish story. We will
not likely save these humans but with a little cash, we can make them more
comfortable.