Macha Mission Hospital

Medicine in the Tropics, Rotation Report, by Kevin Driver
Macha Mission Hospital, Macha, Zambia
March - April 2007

Macha Mission Hospital
When looking for a site to rotate through for my tropical medicine elective, there were several features that drew me to Macha.  I was looking for a place where I could fully experience medicine as practiced in the tropics, somewhere with the resources to diagnose and treat common diseases but limited enough to be authentic to the setting of a developing country and a place for me to hone my clinical skills.  I also looked for a hospital that would be open and oriented to medical students, so that I would have ample support and supervision, but also be able to practice with autonomy and thus really be a benefit to a medically underserved community.  I feel that Macha fit all of these expectations.

I should start by briefly describing the hospital and surrounding community.  Macha Mission Hospital was started as a charitable public service of the Brethren in Christ Church mission to Zambia.  Around the turn of the century, an evangelistic mission was opened in the bush north of the Zambezi River and in the city of Livingstone in Zambia, then Northern Rhodesia.  The region inhabited by a group of the Batonga (Tonga) tribe and was completely rural and undeveloped.  The mission gradually started offering medical care as a public service – in Zambia, as in most of Africa, colonial governments made minimal efforts to provide public services such as schools and hospitals.  Instead these governments relied heavily on mission organizations.  Initially a dispensary of medicines was started and staffed by a nurse, but eventually a US trained physician took an assignment at Macha.  Dr. Alvin Thuma (the father of the present staff pediatrician and director of the malaria institute Dr. Phil Thuma) arrived in 1954.  He soon saw the need for an inpatient facility and by 1957 the hospital was opening much the same as it exists today.  The hospital has always maintained a relationship with the Brethren in Christ Church, but has transitioned because of oversight by the Zambian church leadership and support from the Zambian government, which funds salaries for all the clinical and nursing staff as well as stocks much of the pharmacy.

At present the hospital is quite remarkably equipped and staffed considering its context in the Zambian bush – 50 km or 2 hours over rough dirt roads to Choma, the provincial capital.  The hospital serves a local population of about 150,000 in its catchment area, which in some directions can extend well over 100 km to the next closest medical facility.  Macha Mission Hospital has a total of 208 inpatient beds officially (although the daily census occasionally exceeds that) with male, female, maternity, pediatrics, and TB/leprosy inpatient wards.  Outpatient facilities include a primary health center, a general outpatient clinic staffed by clinical officers and MDs, an eye clinic, and an HIV/AIDS clinic (ART clinic) funded by US-based AIDS Relief.  The hospital has electricity when the power grid is functional with backup generator power and running water (non-potable) from a borehole and dam/reservoir.  Its also has wireless internet access thanks to the Malaria research institute next door (MIAM- Malaria Institute at Macha).   All of these amenities were unavailable in this region before the hospital.  Inpatients services include non-contrast x-ray, ultrasound, and a clinical laboratory with a limited panel of available studies.  The hospital is staffed by American, Dutch, and Zambian physicians, two full-time: Drs. John Spurrier and Kabisa Mwala, and three seasonal/part-time: Drs. Phil Thuma, Lester Mann, and Janneke Van Dijk.  There are also 2 licensate interns (clinical officers – analogous to but with less formal training than US midlevels in training to function as MDs) and several other clinical officers.  The nursing staff is made up of native Zambians, most who have studied at the nursing school run by the hospital.  I found the nursing staff to be generally helpful, as they were invaluable in assisting with translation on rounds, but I felt that often nursing care suffered from the sheer volume of work.  Each inpatient ward of 40-50 patients has only 1 to 4 nurses assigned at a given time; without automated means of taking vitals signs, patients often only have temperatures noted at the bedside.  Of course without any critical care it was often less important what the blood pressure and pulse were; with the level of nursing and the available resources, care for patients in shock is almost impossible.

As mentioned previously, as a government affiliated institution, the Zambian government covers a large part of the hospital budget by paying the salaries of the clinical staff.  I was curious what the salary ranges were, and while I was not able to find that information directly estimates I heard from hospital employees ranged from $200-$300 per month for nurses to around $1500 for physicians, with housing subsidies additional.  Of course the hospital does have other operating expenses, and thus medical care provided, while exceptionally low in cost, is not free.  The cost to an individual Zambian is minimal; inpatient admission is free, as are prescriptions provided by the clinic.  To be seen in the clinic one must pay 700 kwacha (approx. 20 cents).  X-rays cost an additional 5000 kwacha, and if a fracture must be cast the patient is responsible for purchasing the plaster.  The final expense to patients is if an operation as needed.  Operating Theatre fees are on a graduated scale with 10000 kwacha for D+Cs, fracture reduction and casting, biopsy, or skin grafting, 20000 kwacha for a BTL, 35000 kwacha for Herniarraphy, 40000 for an Appy, Cataracts, or elective C-section, and 50000 for Ex Lap, Hysterectomy, and Colectomy.  At these prices, all of these prices are fantastic deals compared to the actual cost, but they can still be prohibitively expense when applied to subsistence farmers who must pay school fees for all children, contribute for family members’ weddings and funerals, and support orphaned or widowed members of the extended family network.

Responsibilities
My responsibilities at Macha were primarily related to direct patient care.  I functioned fully as an independent medical officer (M.O. – physician in Zambia) with some supervision from more senior MDs on the hospital staff.  My duties varied by a weekly schedule; on Monday, Thursday, and Saturday mornings I rounded on the adult inpatient wards, making diagnostic and treatment decisions independently.  Tuesday and Friday mornings were spent in the Operating Theatre (OT equivalent to the OR); in the OT I primarily assisted the senior staff either by scrubbing in or providing anesthesia.  I was able to do small cases independently especially Incision and Drainage and Fracture reduction and casting.  Wednesday mornings involved a didactic teaching session followed by rounds in the TB/leprosy ward.  During my term in Macha I prepared and delivered a presentation on the management of asthma/reactive airway disease for the entire clinical staff.  After morning rounds or the OT I saw patients in the outpatient clinic from 11 am to 5 pm.  The clinic was a combination of adult primary care/internal medicine, pediatrics, OB/GYN, and surgery, so the variety of cases was quite challenging.  Once again there was always a senior clinician available for consultation, but I was responsible for making management decisions independently.  In a typical session of clinic I would see individually from 5-10 patients depending on the degree of complexity.  The cases ranged from quick BP and blood sugar follow-ups/medicine refills, to acute illness requiring admission, to management of rheumatic heart disease, to OB/GYN urgencies such as septic abortion.  Overall functioning in the clinic was the most rewarding part of my clinical responsibilities, as I quickly felt confident in managing common problems and my participation greatly eased the workload of the other physicians.  In the evenings I was also expected to take call from home on a weekly basis, mostly filling in for physicians who were away.  Call involved evening rounds on newly admitted patients and inpatients with active problems; only emergency surgical cases including C-sections, Dilatation and Curettage, and Exploratory Laparotomy required additional assistance.  Practice at Macha was appropriate to my level of training, it was frequently challenging with a steep learning curve, but supervision and consultation was always available if needed.

Clinical Practice at Macha
The best way to describe the difference of clinical practice in rural Zambia is to consider what diagnostic and treatment options that we have available in the bush.  Here’s what we have in terms of diagnostic tests at Macha Hospital: radiology consists of X-ray (without any contrast oral, IV, or otherwise) and Ultrasound (run and interpreted by a gentleman with less than a college education).  The clinical laboratory tests blood for a complete blood count with differential, BUN, Creatinine, Liver Function Tests (without coags), blood glucose, HIV and HBV serology, and RPR (syphilis).  We can also order urinalysis with microscopy, stool examinations, sputum stains for Acid Fast Bacilli (Tuberculosis), cerebrospinal fluid and pleural/peritoneal fluid chemistries and cell counts as well as India Ink smears and cryptococcal antigen (for cryptococcal meningitis).  The lab does Gram stains although they are rarely utilized, theoretically can do cultures (although culture media has been out of stock for the last several months) and biopsy specimens can be sent away to Lusaka for a histopathologist to interpret.  And last but certainly not least is the staple Malaria peripheral smear.  Almost every patient gets an MPS at one point or another even if they have cough, shortness of breath with infiltrates (likely pneumonia), or white cells in their urine and pain with urination (likely UTI).  The malaria smear is truly the one splurge of clinicians here, but more often than not the smear comes back showing at least some parasites.  I suppose one could actually run a decent clinical trial in this context by comparing a cohort of patients who all got malaria smears on admission and treatment if they are positive versus patients presumed to have another illness without a peripheral smear.

Considering what we have to work with diagnostically, clinical decision-making is a matter of playing the right odds.  While one always considers alternative diagnoses we really end up targeting treatment toward the most likely and very little evidence is available to further support or refute that diagnosis.  Considering the types of common pathologies, I doubt that patients suffer greatly from lack of diagnostic tests available in the US.  There are always plenty of cryptogenic cases of abdominal pain in the clinic and while some of them may be due to chronic pancreatitis, cholelithiasis, or occult abscess many of them are probably the same as those patients in the States who get the full work-ups without any helpful information or diagnosis.

Lack of available treatments, on the other hand, does contribute to worse outcomes.  As mentioned earlier, Macha hospital lacks resources and infrastructure for any kind of critical care.  Patients cannot be mechanically ventilated for any period of time, and with only 2 oxygen concentrators capable of producing long flow O2; patients, tragically many children, succumb to respiratory illnesses that may otherwise have survived and improved with effective antimicrobial treatment if supportive care was available for a short period.  In terms of other treatments, Macha has coverage with most antibiotics most of the time.  Obviously new high cost IV formulations are lacking, so you do not see patient after patient on zosyn, vancomycin, or imipenem, but as antibiotic resistance is also less frequent most patients improve on narrow spectrum drugs.  One drug from every class of medicine is typically available in the pharmacy although the drug changes from month to month; i.e. many patients get switched from captopril to enalapril or atenolol to propranolol and back.  Many of these drugs at Macha are out-dated and received as charitable donations from the US.  For example type 2 diabetes mellitus is quite common in Macha, and those patients benefit significantly from expired oral hypoglycemics: metformin and glyburide primarily.  Without oral agents the cost in non-re-useable products for Macha would be much higher, as needles, syringes, and insulin all must be shipped from Lusaka.  It’s expensive enough to check blood sugars that most patients have a fasting blood sample tested monthly (and the lancets are sterilized and re-used).

In several cases the diagnosis and treatment philosophy, mostly in a public health sense, are completely different from the industrialized world.  The first example is cervical cancer.  In Zambia cancer of the cervix is the most common, morbid, and mortal neoplastic disease.  Part of this is due likely to greater sexual transmission of HPV (human papillomavirus) as well as HIV co-infection, which is a risk factor for actually developing cancer, but another contributor to disease burden is the absence of a ubiquitous screening modality, the Papaniculou smear.  In rural Zambia there exists no system of regular health-maintenance much less a gynecology clinic from which women could receive yearly pelvic exams.  As a predictable consequence cervical cancer is diagnosed at an advanced stage when symptoms become evident: vaginal bleeding, pelvic pain, or a pelvic mass.  Cancer can be diagnosed by biopsy, but once again the clinician must have a reason to do a pelvic speculum exam and notice a visible or palpable lesion to have any possibility for early diagnosis.  In my brief time I was presented with a patient after a manual pelvic exam by a clinical officer (a Zambian health professional roughly comparable to a midlevel NP or PA in the US but with far less formal training) who was suspicious of cervical cancer.  I knew that I needed to do a speculum exam but I realized that I had no idea of what to actually look for to determine if the patient actually might have cervical cancer.  I would have known if I saw a papillary, fungating, or friable mass, but otherwise it was not clear what physical findings would raise my suspicion for biopsy.  My training simply had not prepared me for this possibility.  Systems in Zambia may be changing, as there is an ongoing study of using digital photography to take the place of culposcopy to direct clinicians toward high-risk cervical lesions.  Following identification of a target lesion LEEP, essentially cervical electrocautery, is employed to obtain an excisional biopsy.  Such a system would save utilization of medical professionals in short supply, especially pathologists, and enable rapid use of diagnostic and therapeutic interventions.

The second radically different public health strategy here in Zambia is with regard to diagnosis and treatment of Tuberculosis.  While TB is endemic in Zambia and more common than in New York or the rest of the United States, I have found it frustrating to diagnose and treat.  The reason was that I lacked a simple skin test – the Purified Protein Derivative or PPD.  That test quickly grouped patients into those exposed to Mycobacterium tuberculosis and thus at risk for developing active disease and those not.  All patients exposed could then be treated with anti-tuberculosis antibiotics prophylactically.  Tuberculin skin testing is not available in Zambia, first because it is prohibitively expensive, second because it is clinical meaningless as infants are immunized with BCG (which is of at best a marginal benefit in TB prevention), and third because the goal of TB treatment is not eradication but rather treating those with active disease. 

Diagnosing active TB here is also a challenge as chest x-rays and sputum AFB smears are our only diagnostic tools.  First, active pulmonary TB is notoriously difficult to diagnose radiographically as there are several different patterns that do not directly correlate with disease activity, i.e. healed granulomas show up in much the same way as early active TB lesions.  Sputum smears are better, especially with multiple samples but published rates of patients with active TB and with serial negative sputums (sputum negative TB) estimated at 35%.  This is not to mention the fact that at Macha most TB sputum samples are collected inappropriately; instead of 3 samples, one sample from each morning of 3 days, patients are asked to cough up 3 samples one right after the other.  The other complication of using the serial sputum approach in this context is that it was validated for its negative predictive value – i.e. ruling out active (thus infectious) tuberculus disease in inpatients.  Clearly collecting serial sputum samples should increase your positive predictive value as well, but one would have to look at the older studies more carefully.  Thus the majority of our TB sputum sheets come back with 1 mucopurulent sample and 2 samples of saliva.  And to top it all off I can’t count the number of patients who have come in complaining of cough, fever, weight loss and sputum production who by the time the sputum collection vials arrive days later are not even coughing (I know this suggests that they had an alternative pulmonary process, but it is frustrating not to rule out TB).  Finally, with a high rate of HIV/AIDS (estimates of prevalence in Zambia range from 16-18%) relatively more patients will have extrapulmonary or sputum negative pulmonary disease.   Given these challenges, and the global emergence of multi-drug resistant TB (which seems fortunately uncommon in Macha area based on my brief experience), the hospital and associated Malaria research institute is actively researching additional diagnosis and treatment options including a study of sputum culture for mycobacterium and a clinical trial of moxifloxacin for treatment of pulmonary TB.

HIV
As in much of Sub-Saharan Africa, HIV/AIDS is a significant problem in Zambia including the Macha community.  The most recent population based study available to me, the Zambia Demographic and Health Survey (ZDHS) from 2001-2002, estimated the nationwide prevalence of HIV to be 15.6% of adults, with prevalence significantly higher in women than men – 17.8% to 12.9%.  This rate is quite high worldwide, but less than other Southern African countries most notably South Africa, Botswana, Zimbabwe, and Swaziland.  Interestingly, however, the ZDHS and the Antenatal Clinic Sentinal Surveillance report (ANC SS from 2004 most recently) bring out several interesting suggestions of HIV disease patterns and associations.  First and most glaringly HIV/AIDS is much more of an urban disease in Zambia, of the 23 sites surveyed the urban centers clustered at the high end of the prevalence scale, ranging from 15% to as high as 32.3% of pregnant women tested.  Rural sites all had less than 15%, with Macha reporting the second lowest prevalence rate at 7.7% (the lowest reported rate in Zambia was 6.0%, the highest 32.3% in the city of Livingstone, which ironically is the source of all blood products provided for the hospital at Macha).  Second, data shows that HIV/AIDS is a disease of relatively younger women and older men, as prevalence rates of women exceed those of men in their same age group by two to three fold until their 30s and 40s.  Additionally from the ANC SS there was a stepwise increase in prevalence of HIV in women as the age difference between the women and their male partners increased.  Taken together, this suggests that transmission of HIV is primarily between older men and younger women.  Another interesting item from the ANC SS report was regarding condom use.  When women were asked whether they had ever used a condom during intercourse, or during their last sexual encounter, the prevalence rate of HIV was higher in both groups reporting condom use, suggesting that women who have intercourse with condoms are somehow more likely to become HIV positive.

I bring up this final point as it relates to the HIV/AIDS program at Macha.  The hospital runs an antiretroviral clinic that is funded in large part through AIDS Relief.  According to the head of the ART clinic, Dr. John Spurrier, that funding comes through faith-based initiatives set up by the Bush administration and thus does not support condom distribution.  This policy is completely in synch with the local Zambian consensus on the matter; the Zambian Brethren in Christ Church specifies that condoms and other forms of contraceptives cannot be provided to patients unless they are married or have a medical necessity (i.e. Oral Contraceptives for women with menometrorrhagia).  It was difficult for me to reconcile these positions with the reality I have seen in the wards at Macha, as even with a relatively low prevalence compared to the rest of the nation and the region, HIV/AIDS is still a significant contributor to the inpatient population.  And with antiretrovirals suppressing but not curing HIV infection and no vaccine on the horizon, prevention of HIV transmission is still of utmost important.

However another form of HIV protection besides barrier methods of contraception is already available.  In the months before my trip two large randomized clinical trials from Africa reported on a 50% reduction (by intention to treat analysis, post hoc data analysis suggests that the risk reduction may be closer to 65%) in risk of HIV infection among men after circumcision compared to uncircumcised controls.  The trials actually were stopped earlier as it was considered unethical to proceed with such a robust result favoring circumcision.  With these recent studies a part of the context of my trip I expected that the hospital would be quite busy doing circumcisions.  Unfortunately that is not yet the case.  At the hospital we did performed up to 3 circumcisions a day when the O.T. was open, but nowhere near all male babies born at the hospital were circumcised.  The primary indications for circumcision continue to be significant genital infection- i.e. genital warts, phimosis, or paraphimosis.  There will be significant barriers to achieving high rates of circumcision.  One will be to intervene at the neonatal stage; neonates are quicker and easier to circumcise, they do not even require a hemostatic suture.  However, applying infant circumcision in a region where very few women seek obstetric care for delivery will be a challenge.  A second challenge will be funding circumcisions on a wide scale; and finally cultural beliefs will have to be addressed.  There are some African tribes that already practice male circumcision, however, most of those cultures connect it with a transition to adulthood and it is a ceremonial event.  In Macha, from my personal experience, there is a bias against circumcision.  As I discussed with a young mother the need for circumcision to prevent further phimosis in a young child after reducing the foreskin, she asked me, “will my child be whole after?”  The context is a people that are very spiritually oriented; patients can be examined non-verbally because the scars from the traditional healers mark exactly where their pain or problem lies.  Introducing a program of circumcision will require hearing people’s doubts and connecting the procedure with not only the medical model of contracting an unseen virus that only causes disease years later, but also with the value and import of a personal life.

Conclusion
The preceding discussion illustrates well the attraction and challenges of medical practice in Africa.  Africa is living and doing more with less.  It means facing great needs without sufficient resources but with great skill, determination, and compassion.  You are drawn in to understand not only the disease but the patient as a person as well, because both are so different from our own experience.

It has changed me as well; living and practicing at Macha has made me a better clinician, more intuitive, decisive, and thorough.  I have appreciated the degree to which personal and cultural beliefs affect behavior and access to medical care.  I have learned to be independent and self-sufficient but with the humility to accept help or gifts when they are offered or needed.  I am indebted to the people of Macha who with such hospitality and openness have graciously allowed me to work alongside and care for them during my time here.   I also want to thank Columbia University for supporting my course of Medicine in the Tropics, Mennonite Medical Association for connecting me with Macha Mission hospital, and the Rosenbluth and Lattes travel grants especially for funding my trip.