A Zimbabwe elective experience

Iain McNamara reports on his elective in Zimbabwe, where involvement in a war, an economy in crisis, and doctors' strikes ensured a memorable experience.

As I hauled my travel-weary body, along with its grotesquely tied burden of baggage, through the main entrance of Harare railway station, the news vendor saw me coming. "How are you?" he bellowed cheerfully - the universal Zimbabwean greeting which I was to come to know well. "Just arrived," I replied chirpily. He roared with delight as he took my money in exchange for a copy of the Zimbabwe Standard, and wished me a safe journey. The train carrying me to my 10 week elective post in Bulawayo Central Hospital trundled with grim determination through the inky blackness of the African night. With equally grim determination, I wedged myself into the rock-hard corner seat of the elderly railway carriage. I had, at last, been able to untie from my body the 10 kg of stoma bags that I was carrying out from the UK. They had been vigorously pummelled into an uncomfortable and ludicrous looking makeshift cushion under me.

Ignoring the quizzical looks of my fellow passengers, I unfolded my newspaper. It was two weeks out of date. So that's why the news vendor had found our little transaction so amusing. The other surprise that the ?Zimbabwe Standard had in store for me was a prominent front page headline: Junior Doctors Still on Strike.

Twenty-four hours later, I was working in Bulawayo Central Hospital. It was then that I realised the full significance of the newspaper headline: I was a junior doctor in Zimbabwe. I had spent the previous two years under training in the John Radcliffe Hospital, Oxford. Every stage of my development as a medical student had been carefully monitored by watchful senior staff. Suddenly, I had been elevated to qualified status in a foreign country. There was work to be done. In fact, there was so much work to be done that I was beginning to understand what the dying Cecil Rhodes meant when he said despairingly, "So much to do, so little time in which to do it." My first ward round passed in a blur. This baptism of fire saw me performing procedures that I probably would never had done in the UK, and in conditions that are never seen in the UK, despite the impoverishment of the NHS. By half way through the first morning, I had given up trying to explain that I wasn't a doctor and now answered to that title with a certain resigned assuredness. I passed a nurse who greeted me with a welcoming "How are you?" "Fine," I heard my voice reply on smiling autopilot. Actually, I was feeling a lot less fine than I was trying to sound.

I was very fortunate in that I had joined a superb medical team, led by Mr Michael Cot- ton, consultant general surgeon of the hospital. No trainee ever had a better role model. I found myself watching him in action and thinking that if I ever manage to become a fraction of the doctor that he is, I shall consider that I have succeeded in my chosen profession. Thanks to his guidance, by the end of the first week I was much more comfortable in my new role. I felt that I had hurtled down a learning curve steeper than any theme park white knuckle ride. Now I even managed to smile when I saw my name on the 24 hour on-call rota.

Zimbabwe has been much in the news lately. The 20 year rule of President Robert Mugabe, leader of the ruling Zanu-PF party, will be put under serious threat in the parliamentary elections due to be held this summer. The main opposition comes from the Movement for Democratic Change, led by Morgan Tsvangirai. Economic crisis has hit Zimbabwe. Crippling shortages of fuel oil and intermittent interruption to power supplies are daily occurrences. The crisis has been precipitated by the Zimbabwe government's decision to support President Laurent Kabila of the Democratic Republic of Congo in his war against both Rwanda and Uganda. The International Monetary Fund (IMF) estimates that this is costing Zimbabwe £20 million sterling per month. The IMF has suspended financial aid support. As a result of this decision, the exchange value of the Zimbabwe dollar has collapsed and Zimbabwe is defaulting on loans and export guarantees.

This is the disturbing background against which the junior doctors went on strike. To gain a clearer insight into these issues from a medical perspective, I managed to arrange a lengthy interview with Dr Matayaya, President of the Hospital Doctors Association of Zimbabwe. He explained that the strike should have come as no surprise. In recent years, junior doctors have been on strike five times. Health staff are thoroughly demoralised as a result of the depressingly familiar problems of being overworked and underpaid, while suffering poor working conditions and career prospects. The figures available from the Zimbabwe government show that there are only 700 government doctors to care for a population of 12 million. Despite this, the treatment of medical staff makes a career in medicine deeply unattractive. For example, a consultant can expect to be paid less than a civil service secretary working in Harare. While on the subject of pay, it should also be borne in mind that Zimbabwean cabinet ministers awarded themselves salary increases of up to 200% last year to offset the effects of price inflation. Junior doctors are desperately underpaid. Further, hospital accommodation provided for junior doctors is situated on site and usually consists of a single room of inadequate size, containing only a bed and a storage unit, with no toilet or washing facilities. Few doctors can afford to buy and run cars, so all local travelling is by combivans, known as commuter taxis. This of course applies also to night duties and on-call responses.

Added to these personal concerns are the considerable professional difficulties faced by medical staff. I was told that the standard of healthcare provision in hospitals has progressively deteriorated in recent years. In my experience, hospital wards are overflowing with patients and are staffed only by a trained nurse at best and, in some rural hospitals, by nurse aids working without supervision. A hospital doctor can be expected to provide simultaneous cover for up to four different departments as diverse as casualty, neurosurgery, orthopaedics, and general surgery. Patients are routinely given prescriptions for drugs rather than the drugs themselves. Supplies of drugs, antibiotics, alcohol for swabs, and reliable blood regularly run out and cannot be replaced. Even gloves, drips, and syringes are in short supply, exposing both patients and medical staff to body fluids in a country where HIV is officially acknowledged to infect 25% of the population and probably nearer double that. Elective surgery patients are routinely turned away because of lack of pethidine or morphine. Those who are admitted would endure progressive deterioration in hospital food quality and quantity during their period of residence.

The junior doctors came back to work two weeks after my arrival. This took a lot of pressure off the medical staff who had remained at their posts. I was particularly grateful for their return to work. A regular intake of Lariam, combined with the effects of culture shock, ferociously hard and long working hours, and the constant need to work up to the limit of my medical abilities all conspired to create a cocktail of stress that was taking its toll on me. The junior doctors' strike lasted 42 days and succeeded in securing only a fairly modest response from the government.

On my return journey out of Zimbabwe, I passed through Harare railway station. My news vendor friend saw me coming. "How are you?" he bellowed cheerfully. "Older and wiser," I replied with a rueful smile. Leaving Zimbabwe was an emotional experience for me. In a way it felt like being a soldier abandoning his comrades on the battlefield. But I would not have missed the experience for all the lottery money in the Millennium Dome. I learned one immutable lesson - that no matter what difficulties a doctor encounters, professional standards of commitment to patient care must never be compromised. Time and again, the recollection of a favourite saying of one of my tutors returned to me: as a doctor, you put your patients first, second, and third. You come last. The full understanding of just what that means started to become apparent to me during my elective posting in Zimbabwe.

At the time of going to press, the situation in Zimbabwe remains tense. Since the abduction and killing of a white farmer in early April, at least 12 further murders have been committed by "war veterans." The official policy of confrontation with white residents continues. President Mugabe recently appointed a war veteran, Joyce Mujuru, as agricultural minister. As guerilla leader, Ms Mujuru's nom de guerre of "Teurai Ropa" meant "Spiller of Blood." Upon her appointment, the new minister reportedly announced that the government's policy remains unchanged, stating that "Africa is for black Africans. Our fight goes on."

I owe a debt of gratitude to a number of people and organisations who helped me with my elective posting. Here, I give my public thanks to them all. However, I do wish to thank Mr and Mrs Michael Cotton in particular.

Iain McNamara, final year medical student, Magdalen College, University of Oxford
Email: iain.mcnamara@magdalen.oxford.ac.uk


studentBMJ 2000;08:217-258 July ISSN 0966-6494