REFLECTIONS

Appreciating our health care system

Afsaneh Oliver, MD, CCFP

Living and practising medicine in East Africa has been an eye-opening experience. Before coming abroad, I had spent a lot of time in northern Canada doing residency electives and practising family medicine.

I always imagined that rural African clinics would be very similar to the isolated nursing stations sprinkled throughout Canada’s northern communities. For instance, they would be like the tiny station in Repulse Bay, on the Arctic circle, where I worked for a summer. As it turns out, I could not have been more mistaken.

I first came to Uganda 5 years ago and worked with a non-governmental organization in the remote African community of Rakai in southwestern Uganda. Rakai has a measure of notoriety as the first place in Africa—and in the world—to fully experience the AIDS epidemic. Some believe it is where the very first cases were diagnosed. Hundreds of villages were wiped out by the devastating disease that the locals call “slim,” after the effect it has on the bodies of the afflicted.

The hospital for the area is called Kakuuto Health Centre. It has separate wards for male and female patients, a pediatric ward, a one-room operating theatre, a laboratory, and an outpatient clinic. Despite these impressive designations, the hospital has no running water and no electricity. A solar-power array, donated by Medicine du Monde several years ago, now lies broken, its regular maintenance costs far beyond the health centre’s meagre budget.

The ceilings of the wards are black from the smoke of candles and lanterns used by patients at night. Family members are responsible for feeding patients. The few beds that are in the wards have no mattresses, and the floors are covered in bedrolls and plastic eating containers of all colours and descriptions.

A chronic shortage of doctors means that nurses and nursing aides usually run the hospital. These aides, often recent graduates of 1- or 2-year nursing courses, are responsible for most diagnosis and treatment.

On admission, patients are given a bed and probably an injection and some tablets. They are then left to the mercy of God and the kindness of their families. Infant mortality is at 10%. At least two children die every week in the pediatric ward. Measles and malaria are the primary killers, usually because children are weakened by malnutrition. Maternal mortality is 600 per 100 000 births. Midwives, called traditional birth attendants, conduct most deliveries in the villages. Women with complications in labour usually die on the way to the health centre because walking or bicycling are the most common means of transportation. Villagers walk, often barefoot, for several hours to reach the health centre—that is, if they have saved the 50-cent consultation fee (a lot of money for a farmer earning less than $30 per month).

There is no sense of urgency in medical care at Kakuuto Health Centre. One morning, I was bewildered to find that the nurse with the key to the small operating room had casually left town for a day trip. No emergency procedures could be done in the room, and all its equipment was inaccessible.

In Canada, I took for granted the luxury of having easy access to laboratories, x-ray examinations, and an abundance of medications. In medical school, I was taught that resources were limited in northern Canada. While working in the north, I used to complain about not having fast access to various medications or results of laboratory tests. In retrospect, I see that most of the nursing stations are well supplied with emergency equipment and have well stocked pharmacies. Blood tests are easily sent on the next plane headed south, and results are available in just a few days.

In Kakuuto, the only equipment available was my stethoscope and otoscope; the only laboratory test was a blood slide for malaria; and the only medication, at times, was acetaminophen (Tylenol) tablets and chloroquine injections.

I now understand the blessing and the remarkable comprehensiveness of our Canadian health care system. Yes, we face shortages of doctors, nurses, equipment, and money. Still, we are so much more fortunate than most of the world’s population. This is certainly true of the Canadian north, where living conditions are often compared with those of the developing world. The truth is, at least in health care, Canada has made an astonishing commitment to servicing these far-flung regions. There is not one sick Ugandan who would not joyfully accept treatment in a Canadian nursing station.

I am always touched by Ugandan patients who are so grateful for what little medicine we can offer them. They accept disease and death as part of their lives, not as a fault in their country’s poor health care system.

My experience in Africa has been fulfilling and a valuable learning opportunity. Not only have my clinical skills grown, but so have my understanding of and my commitment to health care as a way to appreciate the dignity of human beings. That dignity is exemplified by many of my African patients in their suffering.

Dr Oliver currently practises in Kampala, capital city of Uganda, in East Africa.

Correspondence to: Dr Afsaneh Oliver, PO Box 7793, Kampala, Uganda, East Africa; telephone 256-77-780080; fax 256-41-345892; e-mail afsaneholiver@hotmail.com