November 1996
Volume 60 |
Number 11
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| Return From Zambia |
Carl H. Nielsen, M.D.
During the past four years, I have volunteered for the ASA Overseas
Teaching Program (OTP) for a total of nine months. I was the second
volunteer to go to Kilimanjaro Christian Medical Center (KCMC)
in Moshi, Tanzania, in 1992, and I was the last to go to University
Teaching Hospital (UTH)* in Lusaka, Zambia,
where I spent three months in 1996 (view
photo).
I went to Africa like many other people for the thrill and to
escape the world as we know it. I wrote an article about my experience
that was published in the ASA NEWSLETTER ("Finding
the Missing Link," 57(3):11-13). It was a fantastic experience
both from a personal and professional point of view, and I decided
to repeat it. It has been my privilege and fortune to be able
to do so.
The three following trips were to UTH. When I first went there
in February 1994, I was impressed at how differently OTP volunteers
and the UTH staff functioned together compared to what I had experienced
two years earlier at KCMC. I would like to quote from a diary
entry during the UTH trip:
"The discrepancy between theory and practice is astonishing.
It just does not work in Zambia to teach in the classroom when
it is not followed up in the operating theater. The leadership
of UTH Anaesthesia is weak and inexperienced. As people, they
are all great and good to know, but a functional management they
are not. Why has this mess been allowed to continue? The Zambians
deserve better than this."
Critique was easy. Remedy, at the time, I considered to be insurmountable.
But I decided to take up the challenge and went back to Lusaka
a second time from January through March 1995. I needed to be
able to demonstrate the practicality of my theoretic lessons;
in other words, to give anesthetics myself, but to do so under
the OTP required that the rules be changed a bit. With this in
mind, I applied to the Medical Council of Zambia for a medical
license. Initially, all the copies of my certificates and curriculum
vitae were lost and nowhere to be found (it's the Z-factor). Luckily,
my wife back in the United States was able to locate the originals,
make new copies and mail them to me, and so with a four-week delay,
I could apply again. I was issued a provisional medical license
that was valid for two years.
To teach eight Clinical Officers in Anaesthesia (COA) students
at UTH and a class of medical students at the University of Zambia
without any guidance and curriculum was no easy task. The book
Clinical Anesthesia Procedures of the Massachusetts General
Hospital served as a rough guide for the 60 lectures I gave
during my three-month stay. But real success was only reached
in the operating theater, where I could prove that theory to be
an instrument for better and safer anesthesia for the patients.
I left Lusaka with a good feeling of accomplishment and an assurance
that a local leader would be in place upon my return in January
1996. This promise was not to be fulfilled. Upon my arrival in
January, I found no changes had taken place, and without academic
anesthesia faculty, little teaching had been given in anesthesiology
since my 1995 visit.
From January until April 1996, I volunteered again at UTH. I
again supervised one operating room every day and gave lectures
in the afternoon. I used the method that I had developed during
the previous year's tour, but I think the real impact of my presence
was my function as a role model. Anesthesia records and regular
measurement of vital signs had been uncommon, but once I had located
the storage place for blank anesthesia records, the students enthusiastically
helped me fill them out during the cases I supervised.
Without anesthesia leadership, conditions at the Zambian program
have declined compared to 1993. For OTP to continue to function
in this environment, we would need six to eight seasoned volunteers
who in turn could serve a longer period, e.g., for three to six
months each. However, this is currently unrealistic and contradicts
the stated goal: to encourage the autonomy and self-determination
of these functional but otherwise limited programs and likewise,
to dissuade their dependency on volunteers for service.
Thus, the OTP at UTH was terminated April 2, 1996, when I left
Lusaka. But this should not be considered a failure on the part
of the OTP. OTP is still needed in Lusaka, but it cannot function
without local leadership. We have made a giant contribution to
anesthesia education in Zambia, but I find it sad that there is
no incentive for a medical student to take on postgraduate anesthesia
education in a country of 7 million people, where currently there
are less than 10 anesthesiologists. Without long-term direction
from a credible local anesthesiologist, postgraduate training
programs such as the M. Med. Anaesthesia program stand little
chance in development.
I feel it was fantastic to have had the privilege to be able
to function in two so vastly different anesthesia communities.
After this trip and my reading of Conrad's The Heart of Darkness
and Goulet's The Uncertain Promise, I began to understand
Africa, and it will be a lifelong love for me.
May it be known that I regret to be asked about my vacation in
Zambia and also that I have seen more big game in St. Louis than
Zambia.
* After extensive site re-evaluation and attempts
at assisting the Zambians' recruitment of long-term indigenous
leadership at UTH, the OTP decided this year to terminate its
teaching support there. Further consideration toward involvement
of the OTP at UTH will depend on implementation of certain responsibilities
specified in the OTP Statement
of Agreement.
Carl H. Nielsen, M.D., is Associate Professor
of Anesthesiology at the Washington University School of Medicine,
St. Louis, Missouri.
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