Entering the hospital, I realize I am far from home. The warm, humid air clings to my skin. In front of me are 20 beds arranged side by side and filled with male patients, each separated by nothing more than a curtain. The isolation room is located across the hall, occupied by a patient with multidrug-resistant tuberculosis.
After only hours on the ward, I realize that patients unaffected by tuberculosis or HIV are the exception here, and that the gowns, gloves, masks and individual isolation rooms I use at the Mayo Clinic are not feasible with this volume of patients. In my ensuing days on the ward, I observe patients with diseases that I have so far only read about in textbooks, including toxoplasmosis, cryptococcal meningitis, tertiary syphilis and tapeworms. The approach to patient care differs greatly from anything I have experienced in the U.S., and it soon becomes clear that treatment is far more complicated than trading insulin and beta-blockers for anti-virals and INH.
This was my introduction to McCord Hospital, an independent, semi-private Christian mission hospital in Durban, South Africa. Opened in May 1909 by American missionary surgeon Dr. James McCord, it was the first hospital in the KwaZulu-Natal province to care for patients irrespective of race, and has played an important role in the training of South African doctors, nurses and midwives. With a history of treating the underprivileged populations of the region, McCord is fluent in the challenges of health care delivery in South Africa, including cultural barriers, inadequate education and a shortage of resources.
As a second-year medical student who has always had an interest in international medicine, I jumped at the opportunity to work in McCord's men's ward for a week in February 2009. A Mayo professor helped me set up the visit, during which I assisted interns and performed some procedures like lumbar puncture. I also attended rounds, which often featured difficult patients, like one young man who presented with blurry vision. He was diagnosed with cryptococcal meningitis, secondary to previously undiagnosed HIV/AIDS. After a consult with the ophthalmologist, it was determined that this man, regardless of any intervention, would slowly become completely blind. Had he come in earlier, his vision could have been saved.
Unfortunately, his case was far from remarkable on the ward. I also encountered CD4 counts in the single digits and opportunistic infections. But one of the largest obstacles, as noted by my mentor at McCord, Dr. Neville Chelin, was finances. Poverty not only made patients unable to cover the costs of their treatments, but also created many of the equipment shortages plaguing the hospital. If a patient or his or her family was unable to pay for the required diagnostics or therapies, the physician was left to find alternatives, which Dr. Chelin said contributed to “significant delays and a lack of manpower.”
Since leaving McCord, I have tried to put my experiences there into perspective. In the U.S., millions of uninsured patients feel the financial burden of health care, with rising prescription costs and premiums burdening all socioeconomic levels. This financial burden often manifests as decreased preventive care, producing a more reactive health care system. The same dynamic exists in South Africa, but the severity of the problem there is staggering by comparison.
For example, patients in the U.S. often do have access to preventive care via yearly health maintenance visits that include multiple screening tests. In the case of diabetes mellitus, patients who receive the proper screening tests may be diagnosed and treated as “pre-diabetic” before symptoms of poorly controlled diabetes can manifest. As a medical student, I have been trained to screen for peripheral neuropathies in every diabetic patient, many of whom are aged and obese. Contrast this with the diabetic patients I saw in South Africa, many of whom were young and infected—like the one who presented on first diagnosis with wet gangrene of the lower extremity.
I find myself attempting to explain this stark contrast, trying to understand the similarities and differences in care and outcomes in order to clarify solutions. Do the resources available to patients in the U.S.—screening tests, public education, diet plans, foot care, treatment options—explain the majority of the difference? And if so, would the implementation of U.S. resources in South Africa be successful, let alone plausible?
I don't know the answers to these questions, but I know there are no easy solutions. My own experiences at McCord, and the hospital's great work over the past 100 years, give me faith that the staff there will do all they can to overcome modern health care challenges and provide patients with the best possible care. I also know that I too often take for granted the health care resources available to patients and physicians in the U.S. With the advent of “minute clinics” and a push for primary care, diseases seldom progress to the point I witnessed in South Africa.
As a medical student, my firsthand experiences with the health care challenges facing both McCord and Mayo help me to better appreciate the fundamental and complex health care challenges facing the global community. I look forward to playing a role in helping to solve them.