Zimba, Zambia: A Lesson in Healthcare Perceptions and Access to Care
Meriah Moore
Interviews
2/21/16
Pastor AlickChibbula, Chaplain at Zimba Mission Hospital (ZMH)
Spirituality
Q: Do patients at ZMH seek spiritual guidance?
A: Some patients at ZMH will want their spirit to be tended to as well as their body. Others come to the hospital just to request prayers and to attend the morning devotion. A small number just want to see the doctor. It is very rare that a patient would refuse prayers, maybe one in fifty patients will belong to a denomination such as Jehovah’s Witness and will deny prayers. Even among those who initially refuse, some will change their mind. For example, I was doing prayer rounds on the wards and one woman refused stating that it was against her beliefs to ask God for healing. Then several days later, she discovered she would need an operation and called for me to pray.
Q: Do some people view sin as a cause of poor health or suffering?
A: Some diseases, such as HIV, have been associated with sin and so are more stigmatized. Other people will view illness as a curse. But the curse is not necessarily associated with sin.
Q: Can you tell me more about curses and illness?
A: Some patients have been cursed with suffering. Everyone in their family has an illness, so they have been cursed. Many patients at ZMH will go to aNǵanga (a witch doctor) before they come to ZMH. The can have some power given by demons to affect the curse, but it is limited.
Q: Who goes to the Nǵanga?
A: Anyone who feels that they have been cursed or has bad luck. Christians go in secret. It has become a trend to seek out prophets who tell fortunes and give remedies.
Q: In general, do you think that health care workers should ask their patients about religion or pray with patients here at ZMH?
A: Yes. Illness is only partially physical, the rest is mental and spiritual. Prayer gives hope. You can see [the patient’s] face brighten. Suffering is in the Bible, and it is not always due to sin. We all need encouragement and prayer can do that for people.
Q: How is mental illness or suicide viewed in this community?
A: Suicide is demonic. Quarreling may be involved, but there isn’t always a clear reason. Demons can touch the mind and cause suicide. Prayer seems to help.
Q: How do people grieve over death and suffering?
A:I am sure you have heard the wailing that happens once someone dies on the wards. They wail from grief. Sometimes complete strangers will wail, also. It breaks people’s hearts to see the others cry, so they will cry also. Jesus also wept. During the funeral procession, people don’t wail, but sing more uplifting songs. Crying before the person has died is viewed negatively because it represents that you have no hope in the person getting better.
2/21/16
Dan Jones, MD, Maternal Fetal Medicine and Antiretroviral Clinic at ZMH
Barriers to Maternal/Fetal Healthcare
Q: What barriers keep patients from coming to ZMH for healthcare?
A: There has been an increase in the number of deliveries from 500 in 2010 to 1500 last year. One factor involved in this increase could include better outcomes for infant and maternal mortality. If women see their friends and family delivering healthy babies at the hospital, they will be more likely to come in themselves. But if they see complications or infant death, then they don’t see the benefit and may tend to stay in their bush village and use a traditional birth assistant. ZMH has also improved facilities by building an antenatal ward and expanding the maternal-fetal ward. We have donors who provide baby gifts and give each mom a printed photo of [the mother] holding their baby. Mothers may travel long distances to arrive at ZMH, but know they can ask for help with transport money home, so at least this will not be a deterrent. The WHO is also discouraging traditional birth assists by putting in place some fines since these workers do not have the ability to test for HIV in the bush villages.
Q: I have noticed that newborns are not named right away. Why is this?
A: The infant is not named for 6 weeks and is isolated to home with the mother during this time. This may be just tradition. There also may be some avoidance of becoming too attached to the infant since infant mortality is high. The isolation may be to protect the mother and baby from illness.
Women’s Health
Q: Who makes the decisions about reproductive health?
A: The family. If the woman is unwed, then the father; otherwise it would be her husband. The signature of the father or husband is required on the sterilization consent form before the procedure is done. This may result from the “Labola” or bride-price that is common practice here. Women are property and that includes reproduction, so sterilization forms are signed by the husband. The Labola also makes domestic violence and polygamy more acceptable. If a woman becomes a widow, the husband’s family can take away any remaining money, property, and possessions.
Alternative Medicine
Q: Many of my patients have similar markings on their skin. What does this mean?
A: Many patients try tattooing or herbal liquors from local witch doctors before visiting the hospital. Tattooing occurs over the injured or painful area and is thought to release a curse. It is thought that the curse may need attention before any treatments from the hospital will work.
Q: Who seeks these treatments?
A: Anyone who can’t afford to go to the hospital. They figure there is no harm in trying. Babies and children will often be seen with theses marks. Animism is influential here, so there is more belief in spirits being a cause of pain and suffering.
Stigmas
Q: Are there stigmas associated with certain diseases?
A: Yes, there is a stigma associated with HIV. People coming to ART [Antiretroviral Therapy] Clinic will use false names and some of the employees at the hospital who are ART patients will only pick their meds up from me after hours. Some patients who are able will travel to other cities to keep their status private. Mrs. Chicobela [housekeeper for the Mission] had a sister who was in denial of having tested positive and went without treatment. She then had a son in 2008 and was then found to have progressed to AIDS. She died shortly after fromCryptococcal meningitis. Her son lives with Mrs. Chicobela next to the Big House. She was a leader in her church and may have been hesitant to acknowledge the disease despite encouragement from her family. ART became available in 2004 and is free, so availability is no longer a major barrier.
Q: Is there mandated reporting of HIV or other STIs?
A: No. There is no requirement for doctors or nurses to report the patient’s status to the government or family. There is data collected for statistical purposes. There have been several examples where a spouse has kept positive status a secret from their husband or wife. We will educate and encourage the family to be tested, but it is not forced.
2/22/16
Mutinta Zulu, ZMH Translator
Alternative Medicine
Q: Could you tell me more about tattooing?
A: People view tattooing as protection from bad spirits. It is viewed similarly to immunizations and is very common, especially in rural villages.
Q: Are there any groups that avoid tattooing?
A: Christians
Q: What training is involved in becoming aNǵanga?
A: There is not any official training, but the job is usually inherited from a family member.
Perceptions of ZMH
Q: Do people worry about coming to the hospital for care?
A: Most people would not avoid the hospital. People believe in the doctors and care they can get at ZMH and come any way they can. People come on cycle, by foot, and even ox cart for many miles to get care here.
Stigmas
Q: Do you feel that there are any negative perceptions or stigmas held about any diseases such as HIV?
A: I have HIV, and I get my care here from Dr. Dan. I have no fear coming to the hospital. The people are now seeing that the HIV drugs make your life better and make people live long lives and are eager to be treated. People will encourage their family to get tested. This has not always been this way, but the stigma is getting better. People now do not seem to be concerned about getting ART and seem to be more supportive.
Q: Do you have any comments you would like for me to record?
A: Nobody has to personally pay for care here. No one is turned away. Thank you for coming. People know of Zimba because of the hospital. They know that their family will be saved if they can find a way to get to the hospital. Pray that Dr. Dan and Dr. Joan stay for a long time. They have done so much for us and this hospital.
Journal Entries
Entries were recorded in a paper notebook. Below are two entries excerpted from the journal.
2/1/16
Day 2 in Zambia
Today was our first day at the hospital. Dr. Joan asked Becca to see the surgical patients and I took the medical patients. In the morning, Dr. Joan went to the outpatient department (OPD) to start to see the higher-than-normal number of patients that typically come on Mondays.
As I started to flip through the paper charts to find my patients, a man who spoke English approached me and said “come see this man next door right away.” This man, my first patient, had been admitted the night before. The English-speaking man, who I discovered later to be the man’s brother, stated that the patient had become unresponsive overnight and his fever worsened. From what I could gather, Dr. Joan was not notified of these changes or even of the patient’s arrival on the male ward. The patient had been admitted yesterday by a clinical officer who had not initially recognized the signs of meningitis, but rather, diagnosed “common headache” and had started “brufen” or ibuprofen.
It was clear this patient was decompensating. He was not responsive. He was not attached to anything I would expect to find attached to a patient who was this ill. He would have been in an ICU in the states. There was no IV running, no telemetry or vital signs monitoring. In fact, no vitals had been recorded on the chart hanging on the wooden clipboard since the night before. The BP machine in the ward did not work and no one could find a manual cuff. Thankfully, my translator, Charity, helped me locate a different BP machine and set it up. We were glad to find his BP stable, but he was tachycardic and tachypnic with shallow breaths. He was afebrile, but had received his ibuprofen this AM. No lab data were available yet, but the brother reported some blood was collected yesterday night.
All this time, there was no nurse in attendance, so I was so incredibly grateful for the brother’s diligent watch. After assembling what history and exam that I could, I called Dr. Joan, but she was in a meeting. I called Dr. Dan, who works in Maternity, and reported the case to him. He signed off on my orders for IV fluids, antibiotics, antivirals and antifungals. Our best bet was to treat broadly. There was so little we could do diagnostically: no lumbar puncture, no blood cultures, and no head CT or MRI. Even when we got the labs back in the afternoon, it only included a full blood count (FBC) and HIV test (DCT) – which was found to be positive. I felt soexposed. All I had was my exam and some scratched out history to rely upon. I was sure I was missing something. It was a busy day.
I learned a few more greetings (and butchered most of them) but was glad to find the Zambians gracious enough to smile and say “Oh, you are Zambian already?!” After returning to the “Big House” before dinner, I heard a woman outside in our compound singing in Tonga while she hung laundry on a clothesline. The cloth, called a chitenge and worn as a wrapped skirt, was brightly patterned in bold colors and designs. A barefoot child ran through the bright, sun-soaked grass. Africa is beautiful.
I hope to make a few, meaningful friendships while I am here. I am looking forward to tomorrow.
2/4/16
Day 5 in Zambia
Yesterday I had the opportunity to help Rose, a woman from Philadelphia who is here for two weeks, paint a mural of a sunset in the new medical imaging building. I love to paint! However, our only time to work was after the patients had gone home and our own work in the hospital was done, so we ventured over to the hospital late in the evening. The bright lights in the entryway attracted all manner of bugs into the room, including, a dung beetle the size of a shoe, a spider that charged my foot, and a millipede the size of a snake! (I exaggerate, but not by much!)
This morning I found my first patient was missing from his bed. There was no trace of him. I know he had been critically ill, but some breath of hope flashed through my mind that he must have gone home. Charity informed me that he died in the night. He was 32. I didn’t get a call that his condition had changed. I asked a nurse, but she said she had only come on this morning and was not familiar with his case. His chart was already gone. What was present was the sound of singing from a gathering of mourners. They stood around the mortuary door, a building about the size of a garden shed that temporarily held the bodies of the patients who passed. This building stood not more than 100 yards from the ward’s open windows. I wondered what it must be like to be a patient and hear the songs of mourning. Would this bring fear? Or comfort? Maybe peace?
I was certain of one thing: my patients were much closerwith Death than I had ever been. Death was not neatly packaged and tucked under a mask of embalming make-up. Death was present. It occurred in the bed a few feet away. It was audible through the wailing of the mourners and the songs the next day. It was swift and abrupt and unexpected. It was not dragged out with life support. There was no need for a DNR or a living will to be discussed, because that need would never arise. Whatever sense of control I had over Death in the states with all our machines, medicines, and monitors was scattered. I have to put my faith in the divine plan and purpose of my Creator. We are at His Mercy. It has never been so apparent.
Most Profound Clinical Experience
A 36 year old woman presented to the OPD with complaints of right breast pain for about three months duration. The woman was seen by Julie Baker, a recently retired PhysicianAssistant from Pennsylvania, who was volunteering during the same four week time period as my rotation. Julie reported later that evening at supper that she had seen a severe case of mastitis and possible breast malignancy. She admitted the patient to the female ward where I saw her the next morning.
The patient had delivered a heathy term male newborn four months ago and had been breastfeeding from both breasts since that time. She presented two months ago with induration, pain and swelling of the left breast for about one month. At that time, a mass was also palpable in the right breast in the medial upper quadrant. She was seen by both Dr. Joan and Mr. Kondowe, a Medical Licentiate, who is certified to perform surgery. Dr. Joan treated her mastitis with a five day course of IV antibiotics and then both physicians made a referral for her to go to Livingstone to have a biopsy and see a breast surgeon there. However, the patient did not go to Livingstone due to costs.
Since that time the patient continued to breastfeed on both breasts. The pain, induration, and swelling worsened until the skin on the left breast in the medial upper quadrant ulcerated and began draining purulent material. The ulceration grew in size over the course of the last several days which prompted her presentation. A fleshy white colored mass protruded from the base of the ulceration. No fluctuant areas could be palpated, but the breast tissue was firm, indurated, and tender. Her vitals were stable. Her lab values, including a white count, were all within normal limits.
We started her on IV antibiotics and began wound care. This was extraordinarily painful to the patient. I was rounding on the patient in the next bed while the nurse began her cleaning. Our only pain medication available was the equivalent of Tylenol and ibuprofen, so I requested to the nurse that she give ibuprofen then wait 30 minutes before cleaning. However, the nurse disagreed and said she wouldn’t have time later and continued. After a minute of the patient crying in pain, I stopped the nurse and had her leave it as it was and give ibuprofen. It was terrible to see her in pain.