Seeing Patients

We have now been seeing patients for a little more than three weeks. We usually start our hospital rounds at about 8 AM. Bill visits the surgical and obstetrical patients and Orietta and I check the pediatric and internal medicine patients. At 10 AM we start with the outpatients. We divide the outpatients along the same lines, with Bill doing surgery and obstetrics and Orietta and I handling pediatric, internal medicine and gynecology patients.
There is a wide gulf between hospital care in the western world and Niger. A major factor of course is the lack of money available for health care here. Hospital beds have mattresses covered with a rubberized plastic – often worn through to the foam inside. There are no bed sheets. Patients who are better off will bring a mat with a blanket or other cover from home. Others may have only a straw mat and some have nothing. Most patients prefer to be outside. After our hospital rounds are finished, most of the patients take their mats outside and spend the day on the sand in the shade of the few trees on the hospital grounds. Family members bring food and small charcoal burners and prepare tea or warm food for the patients. The hospital provides two meals a day, prepared over an open fire in the kitchen, . Many patients spend the night outdoors as well. In the dry season it is not a major problem, but when the rains come the risk of catching malaria at the hospital will become much higher.
A handful of drugs for things such as tuberculosis, HIV disease and leprosy are available free of charge to the patients through government programs. Recently we received a container load of medications from Atlanta – based MAP International (Medical Assistance Programs) and these medications are provided free of charge to the patients, but otherwise everything must be purchased by the patient before it can be used. For example, if one of us orders an intravenous antibiotic, the patient’s family must go to the pharmacy and purchase the antibiotic, the fluid used to dilute the drug, the administration set and even the needle, gauze and tape needed to set up the infusion. If there is no money, there is no antibiotic. If someone has to go home to get the money, then treatment is delayed. X-rays are a special problem. The x-ray here doesn’t work, so patients needing x-rays must be transported 35 miles to neighboring Diffa. There is an ambulance available but gas money must be paid in advance by the patient in addition to the charge for the x-ray. It’s the same story here – no money, no study. You might say, “Well, in the States patients have to pay for everything as well.” That’s true, but in the States accounts are settled after the fact. Treatment comes first and we figure out how to pay for it later using a mélange of private insurance, Medicare and Medicaid, cash and funds from other governmental or charitable organizations, or the hospital just absorbs the loss. Here the realities are much harsher.
Nursing care is provided almost entirely by the family. The hospital has a handful of nurses, but no nurses’ aides or other technical help. The nurses transcribe the doctors’ orders for medications or other treatments then communicate this to family members. Family members do all nursing care such as bathing, turning and feeding the patient. The nurses administer intravenous or intramuscular injections, draw blood for laboratory studies, help with bandage changes and check vital signs daily. All oral medications are administered by the patient’s family. The risk of medication administration errors is very high. We speak with the nurses in French and they then communicate the instructions to the patients in their native languages such as Hausa or Fulani. Not only do most of the patients not speak French, but most do not read or write so patients have to remember pills by shape or color. Then they must remember the schedule of administration as well. The nurses maintain that they don’t have enough time to give out the medications. They also point out that it is better for the patients to learn how to take their medications while we are supervising them. They may be right – we will have to give this some thought.
Teaching hygiene is a continuous problem. Many of the patients are from the bush and have had little or no exposure to showers, sinks, toilettes, etc. Showers and toilettes are located in an outbuilding. This is fine for ambulatory patients, but it poses a major problem for sicker patients or small children whose families have to figure out how to cope with bedpans. One enterprising family hit on the idea of putting sand in the bedpan – at least spills were easier to avoid. Again a major problem is personnel – there’s just not the money to have the personnel to help teach the patients.
None of these problems will be solved quickly or easily. It is hard to know where to begin. The four of us along with a local citizen have chipped in the salaries for four custodians so at least we can begin the process of cleaning and hopefully reduce the risk of hospital acquired infection. The shipment of medications from MAP International has been a major help to many patients but the supplies are being used rapidly. We hope that MAP will continue to send us medications but they have many requests from other deserving sites well. Funding, manpower, medications and hospital equipment will be ongoing issues requiring patience, persistence and innovation.
All of us here enjoy hearing from you. Please send a comment from time-to-time.

Steve Humphrey
Maine-Soroa, Niger
17 June 2007