For my medical elective I spent over two months in a hospital in north Madagascar called Hospitaly Voavoa Mafaly (Good News Hospital). My desire was to learn more about the intricacies of providing physical and spiritual care in a low resource setting, among some of the most vulnerable people in the world. The hospital began as a clinic in 1995 and has since developed in partnership with the local church into what one tourist guide described as a “surprisingly good hospital” on the page about Mandritsara, the town it is situated in. Alongside a general medical ward and outpatient service, it now has ophthalmology, dentistry, and maternity services and an operating theatre block where the PAACS (Pan-African Association of Christian Surgeon) residency programme is run to train up local surgeons. It might seem small and simple compared to British hospitals, with less than 100 inpatient beds, no CT or MRI scan, about 10 possible blood tests, and no defibrillator. However, consider this: it is the only hospital with oxygen, the only one with X-ray, the only one with surgical services, and the only one with subsidised patient fees and funds for those who cannot afford treatment. It is quickly apparent that the existence of this hospital is nothing short of a miracle for those who live within the 200km radius that it serves.
Maternity Ward
For my first week, I spent time on the maternity ward. It is the newest extension to the hospital buildings and includes both a delivery suite and a ward where post-partum mothers and neonates can receive treatment.
I was astonished to meet tiny baby H in an incubator during that time. Born premature at 26 weeks (only weighing 820 grams!), he was started on continuous CPAP since day 1of life, because the normal management with intubation, ventilation and surfactant are not available. As a result, his nasal septum had eroded but the tubing had to stay on tightly to keep his oxygen levels high enough. There were a few potential causes for his respiratory distress - lack of surfactant, infection, and maybe a patent ductus arteriosus. There was a lot of careful balance needed – trading off fluids with risk of pulmonary oedema, oxygen with risk of retinopathy, increasing breastfeeds through the nasogastric tube without having a large stomach obstructing inhalation. Seeing him was a highlight each morning as he had a habit of stretching his tiny hand above the wrappings of blankets almost in a wave to the ward round. Over two months of treatment led to baby H finally being discharged as the smallest baby this hospital had ever seen reach this milestone.
Helimission
The undisputed highlight of the trip was going on ‘Helimission’ where a helicopter takes a team to a village, inaccessible by other means, within their referral area to provide screening, treatment for certain conditions, and identifying those in need of referral to the hospital for further care or investigation. There was a spare space on one of the flights and after meeting the charming Andry who was leading that team, it was an easy yes to go along and help the doctor with the clinic. I was warned about showers in rivers, rats in beds, and the lack of running water, electricity, and mobile signal. Those were all easy enough to adapt to, but sadly no one warned me about the rice. The first breakfast was the hardest – a whole “montagne de riz” was tough for the stomach of someone who usually skips that meal, but it was no different for lunch and dinner every day that week. Thankfully I learnt that another team member had been weaned onto rice as a baby and stuck to the diet ever since, so he was able to take most of the foothills off my plate. Dietary challenges aside, it was incredibly sobering to see the barriers to healthcare that I’d read about so often playing out before my eyes.
Over that week, the doctor and I worked over 12 hours a day each day, expect an hour where we pleaded the team to let us go for a little walk around the village. I had in mind the 3 delays model of healthcare access – delays in (1) the decision to seek medical care (2) reaching an appropriate medical facility (3) receiving adequate and appropriate care. This trip seemed to address the first delay primarily. For example, we diagnosed six people with HIV, two of whom were pregnant women and one man potentially with Kaposi’s sarcoma over his arms, who never would have known they needed to head to the nearest town to find ARVT. One gentleman thought he had a recurrence of a dental abscess, but when I examined him there was a craggy immobile mass beneath his jaw that was suspicious for a cancer. A couple weeks after my return to the UK, a surgeon messaged me telling me he’d made the journey to the town for further investigation.
One mother came into the small hut we were working from, carrying a floppy bundle of limbs in her arms – it was her four-year-old son, his eyes staring and glazed over, a bit like a China doll. The malaria blood prick test, which made most of the kids cry, didn’t provoke any reaction from him. We started him on antimalarials, but the next day he was back on the hut’s floorboards looking no different. The government doctor who’d come with us, turned to me at one point and said ‘il va mourir’ – he’s going to die. Under normal circumstances, this child would be admitted, we’d start intravenous medications and get him a blood transfusion, but we were a 4 day walk away, no ambulance let alone roads for them to take, no blood bank, and no additional help. I headed back to the cottage and used the one working phone to contact the paediatrician back at the hospital – the only hope was for a helicopter evacuation. The decision wasn’t simple – the Iranian war had driven up fuel prices which meant the cost of evacuating one child could mean cancelling another trip like this later down the line, risking other lives. The rain made it impossible that day, so we prayed for the family, and so did many of my friends and family back home, that the little boy would survive the night. Thankfully, the next morning we found him on the doorstep, back in his mother’s arm, continuing to stare around, waiting for the helicopter to come through the clouds and pick him up. When the week was over, I got to see him back at the hospital. His haemoglobin level was around 50 on admission (over half what it’s meant to be) but after a blood transfusion and more antimalarials he was doing well and could go home. There had been 40 other cases of malaria we diagnosed and gave treatment for over only 5 days – how many of them would have gone on to be life threatening ad we not been there to catch them early?
Medical Work
The general medical ward (both adult and children) treated very different from the ones I’m accustomed to seeing. Yes, there was heart failure, but in 20-year-olds with rheumatic heart disease. Yes, there are the “bronchi babies” but this time they had HIV and malnutrition as well as a chest infection. Sometimes, we couldn’t get a definitive diagnosis since the lab only had about 15 blood tests, and the only imaging modalities available were ultrasound and film X-rays. We had to rely much more on clinical examination for signs to figure out what could be going on, or we’d just treat for all the worrying possibilities. It was common to have someone come in with decreased consciousness and seizures with a differential including severe malaria, meningitis, TB, haemorrhagic stroke, neurocysticercosis, epilepsy and HIV. Once, when examining a sixteen-year-old girl in this state, I noticed blood in her mouth and a jagged tooth. Unsure how that happened, I asked the family through a nurse translating. Her father and uncle who’d brought her in had strapped her, unconscious, between them on the motorbike they’d used to race at full speed to the hospital. It had taken them all day and at some point, she must have wacked her face into something hard enough to smash her tooth and split her lip. I was shocked by the image that brought to my mind. As with many of these patients, she recovered completely with the right treatment and the hospital dentist even treated her.
Sadly, the hospital team couldn’t save everyone under such severe resource limitations. I once joined a doctor who seemed plagued with difficult evening shifts, so he sent me to help with CPR while another unconscious person was rolled through the door, needing urgent assessment. It was the first time I’d ever done it, and the patient didn’t survive. The scene had much more apathy that I’d expected, having trained for ‘crash calls’ equipped with a team of at least 5-strong. Instead, it was me and two nurses who didn’t seem particularly motivated to go through all the reversible causes of cardiac arrest. When I debriefed the next day with one of the senior doctors, they explained that resuscitation is something that they’re trying to upskill the nurses in, but they have to be careful in choosing what to push and how strongly to do so in a culture where shame is so potent and death is so ordinary. In their words, “the first job is getting them to do CPR at all, then we’ll try getting them better at it”. A couple of times at the morning handover, we heard of patients who died from ‘les gans blues’ (the blue gloves), where the team first spent a few minutes getting the latex snug on their knuckles before starting chest compressions. The quality of medical education here varies wildly, and one of the nurse trainers said she starts from scratch with every graduate from the colleges. They also don’t have a defibrillator here and it’s an interesting point of discussion. In this context - with poor prognosis, no ICU, no capacity for long-term ventilation, and families one admission away from crippling poverty – would it actually save any lives? I don’t think the team has a clear answer, but this is the situation for the time being and something for me to think more about. I was able to participate in a couple of simulation classes as the anxious parent of an unwell child which were designed to help the nursing staff become more structured and confident in emergency scenarios – this is the start of a vision to improve resuscitation care within the hospital.
Surgical Work
Another area where I saw education at the heart of a hospital team was during my time in the surgical block. The team there are being trained under the PAACS programme (pan-African association of Christian surgeons) which seeks to improve the standard of surgical provision. During my stay the resident surgeons underwent the annual exam which involves comprehensive understanding of all surgical fields, with higher pass marks required with each successive year of the programme. On the one hand, this provided far more advanced knowledge than required through the usual training pathways, promoting greater understanding of anatomy and the steps of different operations. On the other hand, a lot of the content wasn’t directly applicable to the resources locally available (e.g. there was no laparoscopic surgery in Mandritsara, yet it is often recommended first line for specific conditions). The diligence of these residents to apply themselves to the rare and precious opportunity for education was admirable, and they also had incredible imagination for research and quality improvement. For example, they were talking me through this NEJM paper which showed that sterilised mosquito nets were non-inferior to the far more expensive mesh produced for hernia repairs.
There are still huge barriers. There was one particularly upsetting story of a young woman who had a backstreet abortion where the instruments used had punctured through the womb and into the surrounding bowel which then prolapsed out of her body. This was when she sought help from the hospital in Mandritsara. Despite multiple operations, her bowel was fistulating and failing, leading to her dropping down to 30kg in weight. I’d seen a woman of a very similar age back in medical school, who was probably one of the sickest patients on the surgical ward, but she had total intravenous nutrition, tissue viability nurses, psychiatrists and so many more resources available. For the Tsimihety girl, it was very hard to know what could be done to help her.
One big success story was the introduction of the recovery room. Emergency laparotomies are incredibly common in this context and had even been nicknamed “the CT scan of Mandritsara” since it was the only way to find out what was happening within the abdomen which was making the patient unwell. They were, however, associated with a high risk of mortality so one of the residents, alongside a nurse from Northern Ireland, had set up a four-bed ‘intensive care unit’, which really was more of high-dependency unit. The intervention led to mortality dropping from 6% to 2.5%, with the biggest effect seen in the most high-risk patients (from 46% to 15.4%).
There are many more stories I could add about the friendship I found among those beautiful red mountains, the roar of the bazaars, testimonies of other tragedies and the faith of those who endured them, and the laughter shared over even more rice. There is one last conversation I will end with, sitting in a garden on a warm evening. A pastor turned to me and called to mind the story of the woman who bled for twelve years – ‘she had suffered at the hands of many doctors before she met Jesus and found healing for her body and soul’. Many of the patients at Mandritsara hospital had also suffered at the hands of other people who were meant to help them. Despite all the limitations and challenges here, the Mandritsara Good News Hospital exists to echo what our Great Physician did, so the vulnerable, sick, and lost would find healing for their body and encounter with Jesus within their walls.
