as an elective during my third year of residency, i am able to do a month of global health! i arranged to come to togo, west africa. i am spending one month at the karolyn kempton memorial christian hospital, also called hospital baptiste biblique (hbb). it is a missionary-run hospital in tsiko, near adeta, togo, a rural area about 3 hours north of the capital lome. it is actually the second largest hospital in the country. on arrival in lome, the hospital had arranged a redundant “welcomer” to meet us prior to customs. she directed us to the wrong line, and then when customs guards asked for a bribe for one of our suitcases, advised us to pay it. we refused, and they eventually let us through without it.
in togo, good medical care is very hard to come by, so the services hbb provides are much appreciated. people in togo must generally pay up front for any hospital services, including emergent ones. even motor vehicle accident victims – even if obviously wealthy – are not resuscitated in emergency rooms until the medical providers are paid, leading to countless preventable deaths. widespread frustration over these practices are one of many drivers of recent protests against the autocratic government. hbb is unique in that they treat any presenting emergent patients first, then ask for payment later. they also supply medicines and supplies for inpatients, which contrasts with most hospitals in the country which require patients or their families to provide supplies and medicines, which they need to buy at markets outside the hospital. all the physicians at hbb are western missionaries (which makes it a good place to learn for a resident such as myself), though there are a staff of togolese physician assistants who see many of the patients in clinic and are the first call overnight. physicians, including myself while i am here, act more as consultants overnight, and do rounds on inpatients and see clinic patients during the day. everyone in the area are subsistence farmers, such that even just the meager salaries of the physician assistants and nurses have essentially created a middle class in the area. most of the locals are people belonging to the ewe tribe, which stretches across the west african countries of benin, togo, ghana and others. there are other tribes in the area as well, such as the fulani, who are more nomadic cattle herders and have their own language. they often come by the hospital, are told how much something like a small surgery will cost, leave, and come back a week or two later with the money, which is often a lot for this part of the world. we had one little fulani feeder-grower premature baby who had been there for weeks, requiring a special high-calorie formula and an incubator. every day it was someone’s job to explain to the grandmother why the baby needed to stay until they reached a certain weight, because they wouldn’t survive life on the road at their size.
i have seen some very interesting medical cases thus far. by far the most common diagnosis is malaria, which often causes severe anemia requiring blood transfusion and extreme splenomegaly. this is the diagnosis for well over half of the admissions. many children also get cerebral malaria which can cause altered mentation, seizures and coma/death. one of my patients died recently from this, likely a brain herniation. typhoid fever is also very common. one child had an intestinal perforation secondary to typhoid, which is a common complication. intestinal amoebiasis is also very common, as are hookworms which are often visible just beneath the skin. impressively, the hospital has developed treatment guidelines for many of these prevalent conditions, so diagnosing and treating them as a tropical medicine novice has not been as challenging as i might have expected before arriving here. there are also a large number of developmentally challenged children who present to the clinic, some already many months old, who have never been diagnosed and have never seen a medical provider before. many have traveled long distances, often even from neighboring countries, to come the hospital because of its reputation. sadly, most of the time there is not much we can do.
a common theme of medicine in the developing world is that people just take longer to present, so their pathology becomes more extreme. i saw a boy the other day whose toothache one year ago developed into indolent osteomyelitis of his jaw, completely reforming the shape of his face over the last year. likewise, many patients with cancer present very late with huge masses. because of the continued strong animism here, some children have scars from cutting attempts by local traditional healers for things like abdominal distension. many people also take “herbs” given to them by these healers, some of which the hospital staff are realizing cause liver failure and resultant uncontrolled bleeding from coagulopathy. there are also many premature infants, often born via caesarean, many of whom die because there are no ventilators if they have respiratory distress. there is the capacity to provide non-invasive positive pressure, however, and it is amazing how well some of them do. there are other cool work-arounds, like giving premature babies nescaffe instant coffee powder in their feeds instead of pharmaceutical caffeine to stimulate their respiration!
