as an elective during my third year of residency, i am able
to do a month of global health! i arranged to come to togo, west africa. i am
spending one month at the karolyn kempton memorial christian hospital, also called
hospital baptiste biblique (hbb). it is the second largest hospital in the
country, and is a missionary-run hospital in tsiko, near adeta, togo, a rural
area about 3 hours north of the capital lome. on arrival in lome, the hospital
had arranged a redundant "welcomer" to meet us prior to customs. she
directed us to the wrong line, and then when customs guards asked for a bribe
for one of our suitcases, advised us to pay it. we refused, and they eventually
let us through without it.
in togo, good medical care is very hard to come by, so the
services hbb provides are much appreciated. people in togo must generally pay
up front for any hospital services, including emergent ones, such that motor
vehicle accident victims, even if obviously wealthy, are not resuscitated in
emergency rooms until the medical providers are paid, leading to countless
preventable deaths. widespread frustration over these practices are one of many
drivers of recent protests against the autocratic government. hbb is unique in
that they treat any presenting emergent patients first, then ask for payment
later. they also supply medicines and supplies for inpatients, which contrasts
with most hospitals in the country which require patients or their families to
provide supplies and medicines, which they need to buy at markets outside the
hospital. all the physicians at hbb are western missionaries (which makes it a
good place to learn for a resident such as myself), though there are a staff of
togolese physician assistants who see many of the patients in clinic and are the
first call overnight. physicians, including myself while i am here, act more as
consultants overnight, and do rounds on inpatients and see clinic patients
during the day. everyone in the area are subsistence farmers, such that even
just the meager salaries of the physician assistants and nurses have
essentially created a middle class in the area. most of the locals are people belonging to the ewe tribe, which stretches across the west african countries of benin, togo, ghana and others. there are other tribes as well though, such as the fulani, who are more nomadic cattle herders and have their own language. they often come by the hospital, are told how much something like a small surgery will cost, leave, and come back a week or two later with the money, which is often a lot for this part of the world. we had one little fulani feeder-grower premature baby who had been there for weeks, requiring a special high-calorie formula and an incubator. every day it was someone's job to explain to the grandmother why the baby needed to stay until they reached a certain weight, because they wouldn't survive life on the road at their size.
i have seen some very interesting medical cases thus far. by
far the most common diagnosis is malaria, which often causes severe anemia
requiring blood transfusion and extreme splenomegaly. this is the diagnosis for
well over half of the admissions. many children also get cerebral malaria which
can cause confusion, seizures and coma/death. one of my patients died recently
from this, likely a brain herniation. typhoid fever is also very common. one
child had an intestinal perforation secondary to typhoid, which is not
uncommon. intestinal amoebiasis is also very common, as are hookworms which are
often visible just beneath the skin. impressively, the hospital has developed
treatment guidelines for many of these prevalent conditions, so diagnosing and
treating them as a tropical medicine novice has not been as challenging as i might have expected before
arriving here. there are also a large
number of developmentally challenged children who present to the clinic, some
already many months old, who have never been diagnosed and have never seen a
medical provider before. many have traveled long distances, often even from
neighboring countries, to come the hospital because of its reputation. sadly,
most of the time there is not much we can do.
a common theme of medicine in the developing world is that
people just take longer to present, so their pathology becomes more extreme. i
saw a boy the other day whose toothache one year ago developed into indolent
osteomyelitis of his jaw, completely reforming the shape of his face over the
last year. likewise, many cancer patients present very late with huge masses.
because of the continued strong animism here, some children have scars from cutting
attempts by local traditional healers for things like abdominal distension.
many people also take "herbs" given to them by these healers, some of
which the hospital staff are realizing cause liver failure and resultant
uncontrolled bleeding. there are also many premature infants, often born via
caesarean, many of whom die because there are no ventilators if they have
respiratory distress. there is the capacity to provide non-invasive positive
pressure, however, and it is amazing how well some of them do. there are other
cool work-arounds, like giving premature babies nescaffe instant coffee powder in their feeds
instead of pharmaceutical caffeine to stimulate their respiration!
