Flying doctors

Anthony Wiskin and Emma Torbé join the flying doctor service in Lesotho

We sat in the cold mountain clinic building and shivered. Looking outside we could see the snow and ice on the huge mountains that characterise this remote and unknown area of southern Africa. This was very different from what we had expected our elective to be like. We had spent most of our time at a missionary hospital on the edge of Lesotho's lowlands, but for a week we were working with the Lesotho flying doctor service.

The service is based in Lesotho's capital, Maseru. The team is made up of one full time doctor and several nurses. The three planes are flown and maintained by American missionaries from the organisation Mission Aviation Fellowship. The service flies to around 10 airstrips in the most remote mountainous areas. At or near to each airstrip is a clinic, which is staffed by full time nurse practitioners. These people do an amazing job, overcoming the harsh living conditions and occasional assault or robbery. Village health workers are attached to each clinic. The work that these nonmedically trained people do is critical. They spread the news of forthcoming flying visits and promote public health issues, such as immunisation programmes, and advocate seeing the doctor instead of a traditional healer.

Everything has to be weighed

Each day started with the painstaking business of weighing everything to go on the plane. The flights take medical supplies for the clinics, along with food for the resident nurses and other requested items. Among the strangest things we carried were a pair of live sheep. After some basic checks we were off. There are usually two flights a day, one primary healthcare flight and one doctor flight, and occasionally specialists from the referral hospital made a trip.

Flying is an amazing and quite a novel way of getting to work. There are rarely any clouds in winter, so the views of the country are amazing. It is possible to see some of Lesotho's natural borders, view wild fires, and see the sparsely scattered villages and small tracks that link them. However, even on a still day there is usually a lot of turbulence, due to thermals off the mountains. This, combined with the gentle rolling motion of the plane, means it is not to be recommended for people who suffer from travel sickness. Landing is definitely not for the faint hearted. The airstrips are the only relatively flat pieces of ground and in varying states of repair, covered in grass and rocks, outlined by stones, and only metres away from the edge of cliffs. Taking off can be as nerve racking as landing; from one air strip we found ourselves looking down at a gorge about 1500 feet deep and then up to see that we were flying straight at another mountain.

Many patients walked miles to the clinic

Once on the ground, we had to walk from the strip to the clinic. This could be anything up to one mile and was generally uphill. It was always amazing to see the number of patients waiting at the clinics for the team, especially as most had walked for several hours to get there. Sometimes it could feel like a market as people would bring fruit and homemade goods to sell while waiting to see the doctor or nurse.

The majority of the service's work is primary health care. The nurses run huge antenatal clinics. These are similar to clinics in Britain; they screen for pre-eclampsia, monitor fetal growth, provide advice, and prescribe folic acid and vitamins. At the baby clinics they offer immunisations, promote breastfeeding, and monitor child development. The week we spent with the flying doctor service was also Lesotho's national immunisation week. In one day we immunised over 450 children.

The doctor trips were quite different. They were a cross between a general practitioner and an accident and emergency service. Some of the patients had previously been seen by the nursing practitioners and asked to return to be seen by the doctor. Others had heard via the health workers that the doctor was coming. Unfortunately, when the plane arrived to pick us up we had to leave whether there were more patients to see or not. This was tough, but the patients operated their own triage system with those who seemed most ill shoved to the front of the queue. The service is not primarily an emergency service like those in Australia. However, if a patient arrived at one of the clinics in urgent need of treatment every effort would be made to fly the patient to the hospital in Maseru

Equipment was basic

Facilities were very basic at the clinics. The only equipment available was a sphygmomanometer, a stethoscope, and, probably the most vital thing, a set of weighing scales. Weight change over time was a very useful tool for detecting serious chronic illness, which could be due to malignancy or, most often in Lesotho, HIV infection. All diagnoses were arrived at by history taking and clinical examination, which can be difficult to do through translators. We could take blood and sputum to Maseru for analysis though we could not say when we would return with the results as all flights depend on the weather.

We saw a variety of conditions: one of the commonest complaints was upper respiratory tract infection as patients presented fearing tuberculosis. This and sexually transmitted infections including HIV were rife in Lesotho. Trauma is very common and mainly due to assault. Whether it was herd boys fighting over cattle or domestic violence, both produced horrific injuries. One herd boy lost the sight in one eye and half his lower eyelid after a stick fight.

At the end of one clinic we thought that we were going to experience mountain life at first hand as the pilot made several unsuccessful attempts to land and then flew off. After waiting another hour or so and deciding that we would almost definitely have to stay overnight in the village, the plane returned and made a final successful attempt to land.

We had an incredible experience with the Lesotho flying doctor service and would like to thank everyone involved for the amazing time we had. We learnt a lot about professional attitudes to medicine and the importance of basics including simple hygiene and history taking and examination.

Anthony Wiskin, fourth year medical student, University of Southampton
Email: ejvt197@soton.ac.uk

Emma Torbé, fourth year medical student, University of Southampton
Email: aw497@soton.ac.uk


studentBMJ 2001;09:171-216 June ISSN 0966-6494