Given the recent shift in attitudes to doctors and medicine in the UK, I should perhaps have expected attitudes here to be occasionally challenging. At home, the intermittent high profile cases of doctors or hospitals getting things wrong has led to a degree of suspicion amongst the public. In Katete, suspicion is unusual, but expectations are often completely divorced from the reality of medical care.
I saw a chap in clinic this week with a high pressure urinary retention. This means he was not emptying his bladder due to prostate problems, but could pass small volumes of urine. The high pressure however causes problems with the kidneys, which were clearly abnormal on ultrasound. Untreated, he will develop renal failure and die. In the UK, treatment would be a catheter then consideration of a prostatectomy once stable. We have a lot of catheters and I explained the situation to him (at length, several times over and through a translator) and offered him a catheter. The only response was increasingly irate protestations in Chichewa, the only part I could understand being "mankwala" (medicine). Clearly someone had told him he could come to St Francis' and get a tablet to take the problem away. He did not want a catheter and would not have it otherwise. In the end, we both left the room frustrated - him because he had not received the (non-existent) drug, me because I know he will become progressively unwell unless he gets a catheter soon.
We had a burns death this week. The patient was a 2 year old girl who had a 20% scald from hot porridge. The injuries were partial thickness and did not need surgery to heal, but a 20% injury is a massive physiological challenge to a 2 year old. In the UK it would be unthinkable for a child to die of this sized burn, and it would require only limited, if any, ITU input. The difficulties come in managing fluid and metabolic (i.e. food) requirements. These increase significantly in both the short and medium term in burns. The best way to manage this is to supplement the patient's oral intake with intravenous then nasogastric fluids and feed. This child had a calorie requirement not far off double that of her usual needs, and was also burnt on the face, neck and abdomen, making feeding painful. I spent a lot of time (probably two hours in total over several days) with nurses translating all of this to the mother. We were initially allowed to put an intravenous line into the child (although this was rapidly pulled out, I'm not sure whether by accident or deliberately by the mother). At no point would the mother allow us to place a nasogastric tube. It transpires that one of her other children had died on the paediatric ward and had had a NG tube. She therefore associated the NG tube with death and refused. The same is often the case with IV fluids, oxygen and lumbar punctures. These are the things done to the sickest patients, a lot of whom die despite treatment. The way this is fed back into the community however must be something like "the doctor put a tube in my baby's nose then he died, so don't let anyone put a tube in your baby's nose". In this case, the child was spoon and breast fed by the mother. At no point did she consume as much as when she was healthy, let alone enough to meet her needs. She deteriorated and died over several days. There was nothing we could do.
Today's case was a little more flippant. A middle aged chap with a cyst on his side. He was adamant that he needed the mankwala to make it go away. I offered him surgery, but he was not interested. There is no drug for cysts, although he probably thinks I'm withholding some magical treatment. In the end, he left unhappy.
I have been wondering whether some of this stems from growing up in a culture where everyone has a local witch doctor rather than GP. Most people seem to trust their witch doctor above us, and indeed sometimes come in to hospital really very sick because they have received traditional remedies. Sometimes we treat them, then they go to the witch for supplementary treatment. One man was lucky to keep his right thumb after a motorbike crash but I reattached it and wired the broken bone together. He came to his clinic review two weeks later pleased as punch with the elephant dung he had put on the wound. One glance at the look on my face and he was at the sink washing it off!
Having never met a witch doctor, I can only speculate, but I suspect they have a treatment for everything. This would cause the attitude that everything can be treated, let alone treated without an operation. To an extent this attitude extends to our nursing staff - it took a lot of effort (and the involvement of the Medical Superintendent) to make the decision to palliate a child with a non-survivable (50%) burn recently.
From the Mzungu doctor's perspective, this creates a difficult tightrope to walk. On one hand, I want to provide care as close to Western standards as possible. On the other, if I don't respect their cultural sensitivities they will leave and get no treatment.
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