BMDF: Outfitting for international and US Christian medical dental missions and healthcare projects

On March 31st, 2008 I embarked on a six-week mission to Banso, Cameroon.  While working at Banso Baptist Hospital, I found that a vast majority of the cases I encountered were indeed preventable.  The Big Five included HIV/AIDS and complications, malaria, tuberculosis, gastrointestinal, and lower respiratory tract infections.  Having experience on the men’s and children’s ward as well as in the outpatient department, I was able to see how these particular disease processes revealed themselves in the different subpopulations of Cameroon’s Northwest Province.

Poverty, behavior, and lack of access all played roles as significant barriers to the community’s health.  Looking first at poverty, the people of the Northwest province make just enough money by selling produce from their farms to sustain daily life.  Sometimes selling their produce is a successful means of income; however, many times it is not as seen in the following photograph depicting a bad day at the market:
 
 

When I asked hospital staff the question, “Where does the average Cameroonian find hope?” the response was, “In Christ and in the land.”  If an obstacle is thrown at an individual, such as an illness, this clearly places a brake on farm production.  No farm production equals no food or income.  In addition, if the illness takes on a more deleterious course and threatens the life of the individual, some how money will need to be gathered from friends and family to pay for the hospital bill – which must be paid up front before services are rendered.  Many times an individual cannot afford to pay the hospital bill, which may be a month’s or year’s worth of income, and thus the individual will not seek out modern health care services.  This brings us to the second topic of behavior (i.e. cultural beliefs and traditions).

Traditional healers have long been utilized by the people of the Northwest Province and continue to be a cornerstone in the local health care system.  Many things drive an individual to seek help from a traditional healer including low cost or free services, word-of-mouth reputation, and deeply engrained beliefs that the traditional healer is the only person who can make an individual well.  Often times, the traditional healer is thought to have spiritual or magical qualities to him, which will help to fight off a disease that is regarded as divine in origin.  Only after seeking a traditional healer time and time again with no results will an individual go elsewhere, particularly if the condition gets worse.  For example, I had an elderly patient with neurofibromatosis who came in with “belly bite.”  After a thorough work up and a lot of clinical suspicion, it was determined that the man was suffering from prostate cancer with mets.  Seen in the following picture is a traditional healer’s attempt to rid the man of his pain by burning it out of him.  Note the multiple horizontal scars in his lower abdominal and pelvic regions:

 

Had this patient seen a physician earlier, a surgical intervention could have possibly made his ultimate prognosis much better.  

Other cultural beliefs that prevent services from being rendered include an overwhelming stigma – specifically with regards to HIV/AIDS.  Many individuals do not want to be tested out of fear that they might have contracted the virus.  Interestingly, others deny the disease even exists.  In fact, public health workers who travel to villages in the surrounding areas have come across a few that will violently throw them out of their village for trying to provide HIV/AIDS education.  

Lastly, if an ill individual wishes to see a physician, he or she may need to travel long distances to do so – many times by foot.  I can only imagine the agony and pain one goes through trekking for miles with severe malaria or a trauma patient riding in van packed with people on roads that more closely resemble ski moguls.  Community clinics have been scattered around the country in remote locations to take care of individuals such as these; however, I have been told that the pharmacy shelves at these locations are many times empty and that the quality of care by the community health workers leaves much to be desired.  Physical access to health care services thus plays a huge role in the health of the surrounding communities.

What interventions are being done to combat some other issues I encountered?  Four specific interventions come to mind: (1) the Life Abundant Program – LAP, (2) provision of insecticide treated bed nets, (3) the Chosen Children Program, and (4) cervical cancer screening.

The Life Abundant Program was created by Pat and Geoff Mitchell to serve as a public health organization for the Northwest Province of Cameroon.  LAP sends teams of health educators, and on occasion physicians and nurses, to small villages scattered about the country.  After arriving via helicopter, Cessna, or van, the educators teach the villagers about preventative health topics such as hand washing, storing food, latrine sanitation, and so on and so forth.  It has greatly reduced the incidence of many preventable illnesses such as diarrhea and malnutrition in the area.  Unfortunately, I came at a time when the LAP team members were on a retreat, so the opportunity to travel with them did not present itself.  The program has been highly successful and is currently regarded as the foundation for public health in the area
 
I arrived in Cameroon at the beginning of the rainy season.  As such, malaria was on the rise.  Sometimes the hospital receives donations of bed nets from individuals or organizations and can then distribute them to those who are at risk.  In this case, BBH sent home an ITN with every patient who is under the age of 5 for free.  Various methods of ITN delivery have been implemented in the past, including selling them to those who can afford them; however, these methods seemed to have failed for one reason or another.  Giving the bed nets out for free to at risk populations (rather than a shotgun approach) seems to be the most logical method.

The Chosen Children Program was started in the 1990’s to provide services for children orphaned by AIDS in four areas: school, nutrition, healthcare, and spiritual.  There are currently 3,500 children enrolled by the CCP; however, because of scarce funds, the program is only able to support 742.  In addition, the CCP will now only accept new children into the program if they have lost both parents to AIDS and have HIV themselves.  With the introduction of the MTCT+ program, the incidence of AIDS orphans has gone down.  However, an interesting ethical dilemma has arisen with regards to the CCP and MCTC+ that the current leadership is currently struggling with greatly.  In the programs, children who are HIV positive have been taking pills all of their lives.  In fact, it has become quite normal for them.  Recently, a few children and adolescents have been asking their caretakers why they are taking the pills if they’re not sick – a valid question.  The issue that the programs have struggled with is when and how to tell the children of their condition – if at all.  On one hand, if the children are not told, then this will obviously lead to more HIV transmissions.  On the other hand, when is a child mature enough to understand the condition and how to handle this new information?  Because there is a great deal of stigma still associated with the disease, how will they handle the intense pressure?  Does keeping the diagnosis silent only add to this stigma?  These are questions that will most likely become more and more important to answer as the many surviving children grow older.  The following photograph is one of the orphans I met on the home visits: 

Lawrence was the field worker that took us on the unannounced home visits to hold the caretakers accountable.  During the home visits, we trekked numerous miles around the edges of the valley.  It seemed as if we were walking up hill the whole way.  I was about to collapse of exhaustion by the time we reached Lawrence’s home.  Lawrence treks large distances everyday and is in wonderful shape – I’m not even sure he broke a sweat!  We were invited into his home for something to drink where we met his wife and two boys.  As it turns out, Lawrence’s wife is HIV positive as well as his oldest son who is 12.  They are both on ARVs.  Lawrence and his youngest son remain HIV negative.  It was a poignant moment when we found out about this news.

During my fifth week in Banso, a group of doctors from Arizona and Idaho paid a visit.  One was an OB/GYN and the other was a family practice physician.  They brought with them a leep machine and hoped to introduce a cervical cancer screening program to help fight one of the largest cancer killers in the world.  All geared up and ready to do a battery of pap smears, cone biopsies, etc they found themselves in an interesting dilemma.  A significant amount of the population was Muslim.  It is a common practice for the Muslims in the area to perform vaginal inspections of women who are about to get married to make sure they are “pure.”  If their hymen is perforated, then the woman is common deemed impure and consequently faces various consequences.  Undoubtedly, performing speculum exams on these women will not help them much if the hymen is to remain intact.  As a consequence, the two physicians shifted gears and started developing a plan to educate the population about reproductive anatomy – hymens to be specific – and how they can be altered/different without having sexual contact.  In terms of the medical care and access to contemporary health care services, there are 5 factors that I believe serve as barriers to quality care at BBH: education of doctors and staff, lack of supplies, the BYOC (bring your own caretaker) and BYOB (bring your own blood) policies, and the payment before treatment directive.  Although these barriers may have been created by the circumstances and are extremely difficult to alter without compromising the hospital's infrastructure, they are barriers to quality care nonetheless.  Many of the physicians have adequate training to treat basic medical conditions; however, I have learned that there is no such thing as CME.  Medicine is a dynamic field and is ever-changing.  There must be a means to educate doctors past their graduation date and for the rest of their lives.  In addition, I found that many screeners and physicians were using inappropriate medications, including antibiotics.