Life as a rural GP

 

Over the past month we have been gradually settling into our roles here. I (Marie) am mainly based in internal medicine and do the rounds there and the ICU with one of the junior doctors. I have also become involved with the occupational health department here in the hospital. It isn’t exactly the same as in the UK as in I am not checking the staff’s immunisation status and conducting ‘back to work interviews’ after a short illness, but providing medical care for the people that work here – basically I am their GP – making my career choice rather fortunate! I do a drop in clinic every afternoon and there is usually a couple to see with conditions that can range from your typical MSK pain to Malaria - so it’s never dull!

The role of a GP doesn’t really exist here in Rwanda. The people’s first contact with healthcare is usually some sort of traditional medicine – I see a lot of patients on the internal ward with tiny scars and burns over their abdomen where they have ‘let pain and badness out’ and I’m sure drinking their traditional medicines is one factor contributing to the high levels of gastritis pain here. After these methods are tried the patient will access the local health centre which is usually staffed by nurses and who will have access to malaria tests and sometimes stool and urine testing. They can manage minor complaints but will send anything they can’t handle to the hospital (where they will meet Matt heading the Emergency department here). In this way you only access healthcare in your more acute stage of illness. The idea of treating chronic disease in the community to prevent admissions is still very new here. Through the occupational health work here I am starting to address that with the staff but I am now also going out with the social health care workers once a week to visit their patients out in the community.

 

 

It is pretty surreal to be doing home visits out here – very different to the UK. Today for instance I walked with Console and Etienne (two of the social workers) about 20 minutes to the first ‘house’ along a dirt road, turning down another smaller lane, brushing past the banana and coffee trees and skirting around the fields of cassava and beans to get to the first house. This is where I met Monique – a widow, whose husband and all her sons had died in the war. She lives alone in a very typical basic house; dirt walls with a corrugated iron roof and no windows. There is an open wood burning fire in the corner letting off a lot of smoke (no chimney) and a few wooden chairs. She has problems breathing and tells me she suffers from asthma but has no medications. It is difficult for her to get to the health centre although she has been there before where she was given an inhaler - which ran out a month or so ago. Monique is very thin, she cannot always get food. Her daughter lives in Kigali and sends food once or twice a month. She has a very wheezy chest and is coughing a lot, she also had pus coming from her left ear which apparently had been ongoing since the war. It is clear she is very poor, malnourished and unwell. I arranged for her to get some salbutamol inhalers and antibiotics but also to be brought to the hospital for a more in depth review as I suspect she has a chronic lung disease and I have no idea what is wrong with her ear or even if it can be fixed.

 

 

It can be frustrating here at times (especially working on the internal medicine ward) as there are limited investigations to be able to make a diagnosis but if you do manage to diagnose someone then there are also limited treatment options (through both expense and availability). Here also, you are hampered by the patient’s resources – being unable to afford long term medication or transfer to another hospital if they need it.

 

The next few visits led me up incredibly steep paths through more bean fields and edging round mango trees and small children who had somehow heard about the mzungu doctor ‘doing the rounds’. The last two patients were an old couple who were overjoyed to see someone come to visit them! The woman had apparently been praying for someone to come and examine her and thought I was the answer to her prayer! She was well apart from bad dental hygiene which was causing her some tooth ache and headache. I gave her some paracetamol and advice to see the dentist as well as regularly cleaning her teeth which came as a surprise to her. They did not have any toothbrushes and it made me think how much we take things like that for granted. One of the staff I seen yesterday seemed shocked that I wanted him to brush his teeth twice a day!

I think she took my advice on board – it is difficult to know when you are speaking through an interpreter whose English is quite basic as well (though much better than my French or Kinyarwandan!). It’s that classic – ask a question, the patient talks for a few minutes pointing to her leg, ear and gesturing outside and the interpreter turns to you and says ‘she has problems with her ear’! I’m pretty sure that is not all she is saying! It is a long process asking a lot of direct questions of which very few get a direct answer.

 

 

 

All in all, despite the language, the frustration at delay in treatment and the long hot walks between the houses it is a privilege to be let into these patient’s homes who have never known a doctor to come and see them or anyone before. To hear their stories and see how they live their lives is very eye opening and I am looking forward to developing my role as ‘Rural GP’ over the next few months.