A Half-day at an Outreach Clinic

8/8/12

Posted by Amanda Thornton, MD (a third year Internal Medicine resident from Kaiser Permanente, Oakland while on a global health elective in Lusaka, Zambia with University Teaching Hospital).

The late morning after my call day, I went with one of my attending physicians to a outreach clinic in an underserved area outside of Lusaka. To understand the clinic- you have to first understand how the health system is organized here. The WHO guidelines rule health policy- which is, again, different from the relative freedom we have in the U.S in choice of treatment. I’ve been memorizing the WHO guidelines on malaria treatment, Tuberculosis and HIV management because they are the backdrop to every physician’s training here and I’m far behind. According to my attending physician, for every 1,000 people, there is supposed to be at least one health check point or clinic which is staffed by at least one medically trained person. If the problem identified at the clinic cannot be handled by the clinic, then the patient should be referred to the hospital or secondary clinic, for which there should be one for approximately every 10,000 people. Then for every 100,000 people there should a tertiary hospital like UTH which has advanced medical technology such as imaging (CT and MRI), dialysis and surgery- and the secondary clinic has the ambulences to take sick patients without trainsport there.

So this clinic was created with funds from the pediatric department- in an area where the people are too cash poor to afford the bus that stops in the middle of the village for the regular check ups children need during their development. I had initially thought that this meant that people would be starving, but actually, it just meant that they grew the food they needed, and most of their solvency was tied into the land and the house they were living in.

Though the clinic started seeing only children, frequently the women and the grandmothers who brought the children would ask the pediatricians for advice, and so the department at UTH requested that an internal medicine or family medicine practitioner also see patients once a week.

Because the clinic is only open for a few hours once a week, when we arrived, there was a reception office full of people. Furthermore, because the pediatrician who usually accompanied my attending had other commitments which precluded the 50 minute drive over difficult terrain it takes to get to the clinic, we saw women, men, children and infants.

The building itself was small. There was one waiting room which took up half of the floor space, one pharmacy/all purpose room. There are two examination rooms- without electric lighting. The shy girl who demurred an examination by my male attending but agreed to be examined by me had to be examined in the light of the window; obviously the clinic is only staffed in the daylight.

The clinic has two nurses who help run it as well. They took vital signs before patients were sent in to see us- and were in charge of the limited but comprehensive pharmacy formulary. The clinic pharmacy had an ubiquitous all purpose cough syrup, which given the changing weather around this time of year and the likely codeine and acetaminophen combination components, nearly every patient had brought their own container to fill. It also had anti-inflammatories (ibuprofen and prednisolone) and salmeterol (in pill form). For antibiotics, this week, they had erythromycin, ciprofloxicin (incredibly cheap around here- it serves the same as amoxicillin-clavulonic acid does in the States, and is used more broadly for urinary tract infections and gastrointestinal infections as well) and amoxicillin. There was only one thing for hypertension- a diuretic, and the formulary apparently changes depending on what is most cheaply available.

It was a relief to see people who were suffering from lighter complaints than those I see on a regular basis in the hospital. Anyone who is seen in the clinic has a medical record written in a inexpensive children’s journal which the clinic keeps- and some people had been seen regularly for a few months and had several visits filled in.

Nearly everyone had “the flu” which is what people here call an upper respiratory infection here. Some of the children also received antibiotics- those suffering from the complaint for more than 1 week or with copious greenish secretions. My attending corrected some of my more conservative antibiotic prescription patterns- when treating people of unknown antiretroviral status who you may never see again and who do not come to the doctor unless their illness is seriously affecting their work, you cannot afford to undertreat. If you do, there’s a risk of the person who reported ear pain or a persistent sinus infection may show up in the filter clinic with meningitis.

The clinic has no lab facilities or imaging- we referred a few people to UTH for imaging. It also has no real facilities to deal with emergencies- the old woman (who didn’t know her age- actually fairly common in people who were born before the revolution, especially those in the country, who count their age by events) who presented to the clinic with hypertensive urgency/emergency was sent to the nearest secondary hospital. The patient with the asthma exacerbation- no peak flow meters in the clinic- was handled fairly effectively as well, though the patient was encouraged to present to the nearest hospital for further problems.

The clinic also does not provide prenatal care- and I was surprised to note, abortions are illegal in Zambia, even ones very early in gestation. Women with unwanted pregnancies have very few legal options- and their options are handled by the prenatal clinics.

All in all, it was a great experience, and I can see why Zambian physicians would be happy to volunteer there. It’s part of the slow process of changing the culture of patterns of medical access- showing that doctors can help with concerns that are not life threatening… yet… and keep people in better health for longer. My attending just published a paper on patients with stroke- and he reported that no one in the hospital had come in sooner than 12 hours than the neurologic deficit started. This would mean a woman with hemiparesis would be brought in by her family nearly half a day after the deficit started- and not because the family lived far away or did not have access to transportation. People here seem to come to the hospital when they’re afraid they might die otherwise- which is several hours to days to weeks after physicians would prefer to see a serious medical problem.