Happy New Year from the Electives Network!
In our first newsletter of 2017, we bring you a pair of case studies which were both written by medical students following an elective placement in midwifery-related fields in Africa. After her neonatal medicine elective in Zambia, Laura Shorthouses wrote a thought-provoking article on the ethical dilemmas students can face upon first seeing the differences between western medicine, and the reality of healthcare in developing countries. Jasmin Kramer’s article recounts her experiences in three different departments of the Mawenzi Hospital in Moshi, Tanzania, including a stint in the maternity department.
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Laura Shorthouses' thoughts on ethics during her maternal, neonatal and child health elective in Zambia
In her case study, Laura Shorthouses writes an in-depth account of how quickly we can project our own ideas onto new environments and how these can stand in the way of understanding the new as an independent entity. These prejudices can sometimes be a barrier to good practice.
Livingstone Central Hospital in Zambia: A reflection on ethical dilemmas encountered during my maternal, neonatal and child health elective
During my five-week elective I gained hands-on experience in maternal, neonatal and child health at Livingstone Central Hospital, and in three local community districts served by the hospital – Linda, Maramba and Mwandi. Working days contained rich and varied learning opportunities to accomplish my goals and develop professionally, but also provided powerful ethical dilemmas and lessons in people, life and myself; forever shaping my future medical career and character.
I was introduced to the labour ward on my first day, which was an unforgettable first impression. From the initial ethical ‘horror’ I felt and not wanting to return to the ward, to the in-depth personal and professional thinking it evoked, to finally overcoming it – it was a life-changing experience in growing as a future doctor and person. In a large curtainless room three women were giving birth in silence and were being shouted at when they made a noise. The first delivery I witnessed in Africa was stillborn twins.
They were left for over five minutes unwrapped on their mother’s lap while the midwives cleaned the floor. They were then disposed, without any opportunity to say goodbye. I wanted to comfort the mother but felt it an inappropriate first impression. Instead, I stood there shocked holding back tears. I found this opening hour to ‘obstetrics in Africa’ cruel, insensitive, detached and degrading with no patient empowerment. I did not want to go back and play any further part.
As the initial shock of witnessing a different cultural and geographical approach to labour eased, I shamefully realised I was being judgemental. I was impinging my ideology of ethical practice onto others, disregarding their culture and traditions as though the ‘western’ approach was best. I was determined to overcome this dilemma by returning to the ward and learning more about their culture and ideology. I came to understand that Zambian women have adopted a tough ‘carry on’ exterior because sadly losing a baby is more of the ‘norm’ in their culture than mine, as well as them feeing grateful to still be alive post childbirth – to them it is the best way of moving forward. They prefer silence because it is important for them to introduce their baby into a calm environment. Being silent is their personal, empowering and autonomous choice, rather than the oppressive, degrading and paternalistic one I had wrongly assumed. Subsequently, whilst this was still foreign to me, I had chosen to work here and believed it important to respect their wishes and culture moving forward. I therefore felt I was subconsciously empowering my patients and respecting their autonomy, thus providing good medical practice; albeit in a very different way to back home.
The English language, whilst the official language of Zambia and that of medicine, was predominately limited to wealthy, well-educated families, or to young children benefiting from international volunteering projects teaching English. Consequently there were several occasions, notably in Obstetrics and Gynaecology, where I needed translators. These were not third party impartial translators like in the UK, but either other doctors, the patient’s family or their own children. Where possible I would have preferred doctors, however I did not want to ethically burden my overworked and understaffed host, so relied mostly on the latter two. Taking Obstetrics and Gynaecology histories involved asking many sensitive, intimate and personal questions, which I found not only uncomfortable asking others, but also took longer. I overcame this discomfort by remembering it was necessary to gather information to treat effectively. In Paediatrics, I tried to obtain the history from the child, which given their good level of English was more possible and I preferred. The result of this experience however is that my clerking and clinical judgement has significantly improved in preparation for becoming a foundation doctor.
Venepuncture and cannulation quickly became my daily jobs – I did more of these in five weeks than in the past two years of clinical experience. My ability to improvise to different methods has also been developed in preparation for my future career, as instead of using a tourniquet I would use a rubber glove. I also performed speculum and bimanual examinations for the first time. This was important to me because I did not want to do them as a doctor for the first time with no assistance. I worked within my competency and the staff guided me. I am also more proficient at obstetric examinations on pregnant ladies (as opposed to plastic mannequins), can use a pinard stethoscope in practice, and competently perform newborn checks.
To conclude, I learnt that a complex relationship exists between medical ethics and external influences. Successfully navigating cross-cultural medical ethics requires sensitivity, non-judgemental attitude, and enhanced communication and clinical skills. Through a rich and enjoyable personal elective experience, this study supports the evidence that electives in developing countries can be beneficial to all, and without hesitation I would recommend such electives to future medical students. I wanted to experience Sub-Saharan African medicine with a view to future work there and to clarify my career goals; this desire has been significantly strengthened.
Thank you very much to the ‘Institute of Medical Ethics’ for a Medical Elective Bursary.
This version of Laura’s article has been edited for our newsletter. To view the original case study, which includes academic references, please click here
Jasmin Kramer, a medical student from the University of Mainz (Germany), writes about her placement in the Mawenzi Regional Hospital in Tanzania
I stayed at Mawenzi for four weeks in September 2016. Mawenzi is a hospital in the center of Moshi and there are local patients and local doctors too. The doctors in particular speak very good English because their whole studies were in English, and some nurses speak it well too. Most of the patients speak Swahili and some of the younger ones also speak English.
Dori is the Secretary and she organizes everything concerning volunteering. I really like the fact that on each ward, there are two volunteers maximum. This allows you to be able to observe a lot of what is going on. In my opinion it’s a good idea to change ward every week or two, because it’s interesting to have a look at different wards so that it doesn’t become boring. There are a lot of differences between the wards. In the following text I will share my experiences in the paediatric, OPD (outpatient department), general surgery and labour wards.
Every Thursday and Friday morning at 8 o’clock there is a general morning report in the building next to the OPD-ward which was mostly in English. Especially on Fridays, there was always a good presentation about an interesting topic such as ADHD, new international studies or alcohol addiction.
For the first three days, I stayed in the paediatric ward. There were two separate rooms, one for children with infections and the other for all the rest. Sometimes there were some patients in the maternity ward or in the Kangaroo ward (premature babies). During my time there, there were not many patients, around 8 at a time, but there were a lot of doctors and interns. So there wasn’t a lot to do. At 8 o’clock in the morning, they started with the morning report and this was in Swahili. After that, they do ward rounds to see the patients. Sometimes this was not done together as a group; the doctors separate and each of them goes to see one child. This was a little bit sad because you have to decide which doctor you want to follow and therefore, you can’t see all the patients. I always had to ask for translation so I could understand a little bit of the child’s history and problems. Usually, after the ward round it was very calm and there was nothing to do. So I often went home early and after three days, I decided to change ward to see more. The amount you could see or learn in the paediatric ward depended on the number of patients that visited.
The OPD (outpatient department) ward is like a polyclinic, so you can see a lot of patients every day. Some of them only need an antibiotic and others may need an X-ray to decide whether they need a cast. Some of them are told to stay in the hospital and go to another ward for specialist treatment.I preferred to start work there at 8.30 a.m. or later, because they do the morning report in Swahili and so I couldn’t understand anything.
I spent the whole day with one doctor, so I could ask him to translate for me, ask the patients some questions, do examinations together, and discuss and decide what treatment was required. Don’t be shocked about the use of antibiotics; I hadn’t known that they used antibiotics that often. I spent most of my time with Dr. Peter or Dr. Victor. Both were very friendly, spoke English and explained anything I didn’t know. Most of the time, I finished at 2 p.m. or earlier. It was interesting to spend a few hours or a day in one of various specialised areas in the hospital, such as the plaster cast room, the dentists or the little operation room.
The surgery ward includes one ward for females and one for males. The daily routine starts at 8 a.m. with a morning report in English!! That also includes more rounds. You really can see a lot of patients and you learn a lot about their medical history. After drinking tea, there are different options of what to do: on the ward you can help a doctor or intern to change a bandage, clean a diabetic foot, treat a burned child, do some minor surgery etc. One of the doctors is in the building where the meetings for consultation are located – here you can see different surgery cases and learn a lot about treatment options. Every Tuesday and Thursday the surgery team has the opportunity to use the operation room (theatre) for surgeries. You can see different things and if you want to you can ask to scrub in and assist. I really liked the days in the operation room because most of the time something was going on or you could sit in the little tearoom and talk with others or eat chapatti (every day a woman comes to the changing room and sell some little snacks – very tasty!!).
I really liked the surgery ward because of the very friendly team. Everyone tried to speak English and felt comfortable with explaining things. I could see a lot of impressive injuries and it was very interesting to see the way they were treated.
The labour ward includes three rooms: one with all the women in labour – when they arrive they stay here for a while; if it’s getting serious the women go to the delivery room and after birth the mother and child go to the “mother and child health center” (postnatal room). Amongst all the pregnant woman and babies you have other women with gynaecological problems. Sometimes it is very lazy and sometimes very busy in the labour ward, it varies from day to day.
There is also a small operating room where they do curettage and other minor operations. While I was there the doctors didn’t do a ward round together. Sometimes it was just one doctor, or at other times the interns, who go and check the patients. So you have to pay attention to when they start. It was also very good to make friends with the nurses, because they do most things and you could learn a lot about midwifery, see some natural births and even assist. On Wednesdays and Fridays the doctors go to the operation room for gynaecological surgeries. A C-section can happen at any time and is very interesting to see. In this ward, you could decide when you wanted to finish for the day. I didn’t do a night shift but I heard from others that it was a good thing to do on the labour ward.
In summary, I had a great time at Mawenzi hospital. It wasn’t that practical, but I saw a lot of things I would not have seen in Europe and learnt a lot about limited treatment options. Particularly, what it means to wait, to take things “pole pole” (as they say in Swahili), drink some chai and communicate in English. I really liked the people at Mawenzi. It took me a little bit of time to get to know them but then they are so lovely and friendly – we had lots of fun!
Jasmin Kramer, Medical student from University of Mainz, Germany
This article has been edited and abridged for our newsletter. The original article, which includes a list of useful things to pack for a placement at Mawenzi, as well as some tips for free-time activities in Moshi, can be found here
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