Introduction

I undertook my 7 week medical elective at Chikankata Mission Hospital, a 200-bed rural general hospital serving a catchment area of 100,000 people in the Southern Province of Zambia. It is situated about 125km (2.5 hours drive) south of the Zambian capital Lusaka, with the nearest town being Mazabuka, about 1 hour drive away. My rationale for choosing Chikankata was firstly the really positive reports I read of other medical students' experiences at Chikankata and other mission hospitals. Secondly, I was keen to see tropical medicine in a resource-poor setting very different from what I am used to in the UK with a view to deciding whether I would like to work in such a setting in my future career. I was not disappointed – Chikankata far exceeded my expectations and gave me some of the most memorable weeks of my life!

The Mission

Chikankata is run by the Salvation Army on behalf of the government – so it is partly government funded but also relies on donations from around the world. It is a Christian hospital, evident in the ethos of the hospital and in other small ways such as a prayer said at the end of every morning handover meeting. I was particularly keen to visit a mission hospital as this would be my first time seeing how a hospital can operate as a faith-based organisation to serve the community.

Besides the hospital, there is also a primary and a secondary school (which is a boarding school), nursing school, College of Biomedical Sciences, a Salvation Army church and even a radio station on site. Just outside the mission, there are more churches of different denominations and also the marketplace – here you can buy fruit and veg for very cheap prices (e.g. 4 good sized tomatoes for 2 Kwacha or 20p) and although there is no supermarket (the nearest being a Shoprite in Mazabuka) most necessities are sold in the small shops here. Here you can also buy chitenge material which local women wrap around themselves, but can be made into various clothing and souvenirs by one of the local tailors. All hospital staff and most nursing and biomedical science students live on site and there is a really good community atmosphere.

Culture

Zambia is an English-speaking, politically stable country and generally safe which makes it a popular destination for people looking to do short term volunteering, especially in healthcare and conservation projects. Although Zambia has a vast land area of 752,600 sq km, the population is just 14.5 million as very little of the country is urban. So there is really beautiful green landscape and Zambia is blessed with lots of arable land that can grow anything! The main cultural difference is how laid back everyone is compared to the UK. I recall in my first week being told by the English hospital administrator how worried he was when he first started his job and the hospital had run out of blood supplies. He soon realised in the various challenges he faced in managing the hospital that worrying wasn't the way things are done in Zambia and he started to adopt the more care-free Zambian attitude over time. One thing that really impressed me about the hospital is how staff make the best of whatever resources are available without complaining. Another great thing about Zambia is how warm and friendly people are – coming from studying in London, it took me a while to get used to everyone saying “Good morning doc” in the corridor even when I'd never met them before.

Although Zambia's national language is English (hospital staff speak English, ward rounds are conducted in English and medical notes are in English), the local language of people in that area is Tonga and many of the patients who missed out on school didn't speak English. This meant I needed a translator (which would usually be a nursing student) to take histories from patients most of the time.

Accommodation

Elective students are housed in the 6-roomed student accommodation centre (SAC). Each room has its own en-suite shower and we shared a big kitchen, where we cooked together and where many good times were had! SAC was cleaned and our beds were made every weekday by the wonderful Lina. We were also well looked after by Matros who was in charge of maintenance for the Mission and checked on us daily, lending us his barbecue set when the power failed a few times!

The hospital

The main hospital departments are:
• Paediatric Ward
• Maternity Ward (Prenatal/Labour/Postnatal)
• Female Ward (Surgery/Gynae/Medicine)
• Male Ward (Surgery/Medicine)
• HIV Clinic
• Chest (TB) Clinic
• OPD (also called the Hospital Associated Healthcare Centre or HAHC where patients are seen by clinical officers on arrival at hospital)/ Admissions Ward
• Filter Clinic (staffed by doctors – follow-up of patients after discharge and for patients referred from OPD by clinical officers)
• Maternal and Child Health (run by midwives/nurses - includes antenatal clinic, family planning, under-5 growth monitoring/vaccinations)
• Operating theatres
• ECT (Epilepsy Care Team)
• HARD (HIV & AIDS Response Department)
• Environmental Health

There are currently 6 doctors at Chikankata: Dr Chilaika (the Medical Superintendent) and 5 general medical officers, each in charge of a particular ward(s) – Dr Misago (Chief Medical Officer), Dr Kalenga, Dr Kurian, Dr Bwale and Dr Mijere. They were from a range of backgrounds having trained in the Congo, Rwanda, China and Zambia.

Each day would start with handover followed by ward rounds (sometimes with a Zambian scone from the canteen in between). In the afternoon, the doctors would see patients in Filter Clinic (also known as Room 8), which was often very busy, particularly on a Monday. Elective students were free to shadow any doctor and rotate around different wards, see patients in OPD, sit in one of the clinics or go on an outreach trip. Every Wednesday, the “Doctor's Trip” took place – an outreach clinic in one of the neighbouring villages, each village being visited monthly. This was a great opportunity to consult patients on my own (with a doctor nearby, often in the same room so I could easily ask any questions) and learning how to manage common complaints on my own. My confidence improved greatly especially in learning correct drug doses for the most commonly prescribed drugs (e.g. painkillers and antibiotics). I also learnt to be flexible in my management because often the preferred drug was out of stock in the rural health centres so an alternative would have to be given (e.g. paracetemol instead of ibuprofen for musculoskeletal pain). On other days of the week, there were Maternal and Child Health outreach trips where public health talks were given to mothers, I helped weigh babies and could assist in antenatal clinics in the village health centres.

Clinical highlights

On my first day in hospital, I observed my first BID (brought in dead – a term given to a patient who dies within 48 hours of arrival at the hospital) and was taught how to certify death myself – it was my first time checking pupillary reflexes and not seeing a response, auscultating the heart and lungs to hear no sound… A strange experience I didn't expect to have on my first day, but also very useful to learn ahead of starting FY1 in a few months.

I don't think there was ever a boring day – there were always a variety of patients with a variety of illnesses. From the patients with witch doctor tattoos who had delayed seeking medical help till they realised that traditional medicines had not worked, to patients with AIDS-defining illnesses I had only read in textbooks such as Kaposi's sarcoma, to the many children with fractures from falling (often presenting late and with malunion) and pyrexia of unknown cause. I was able to try my hand at applying plaster of Paris and was taught how to do a lumbar puncture by the doctors. There were patients with renal failure secondary to tenofovir therapy, others with complications of pulmonary TB including the biggest pleural effusion I'd ever seen. I assisted with management of a post partum haemorrhage (which was eventually found to be secondary to a cervical tear). There was also a man I saw with one of the other elective students in outreach clinic who came in with a “headache” and “back pain” as presenting complaint; later in the history it seemed the problem might be an “STI”. Following more detailed questioning and examination, we finally discovered that there was a mistranslation and the patient actually had a recurrence of anal fistulas and haemorrhoids. Dr Misago confirmed our suspicions and we referred the gentleman for surgery the following Thursday. It reminded me that often patients can come in for one reason, but actually have an underlying more serious concern that they're too embarrassed to mention from the outset. Gaining trust, establishing rapport and asking the right questions is always important to get to the bottom of every patient's complaint, even in a busy clinic. Theatre day was every Thursday, where I was able to observe, scrub in and assist with various operations including C-sections, umbilical hernia repairs, ganglion excision, abscess drainage and debridement of infected wounds.

Another highlight for me was conducting a ward round together with 3 of the other elective students a few weeks into my placement. The hospital was down on doctors due to illness and training workshops so we were asked by Dr Misago to do the men's ward round on our own. It was a little nerve-wracking at first, but such a useful experience and putting our 4 heads together, I felt more confident about the clinical decisions we had to make for patients. (It was also reassuring knowing that Dr Misago was only down the corridor on another ward ready to answer any questions we had!)

One of the things I saw on the wards that will always stick with me is how one particular doctor made efforts to share Jesus with the sickest patients on her ward. Dr Kurian would make sure screens were put up around the patient and with the Sister-in-Charge alongside her she would ask the patient “What does Jesus mean to you?” She didn't want anyone to die on her ward without first having the opportunity to give their heart to the Lord. It is humbling to know that this sort of practice is very acceptable in a Christian nation like Zambia, especially in a mission-setting, but not commonplace (and probably a bit frowned upon) in the UK. It was also so refreshing to see a doctor caring about the spiritual salvation of her patients just as much as their physical needs.

Non-clinical work

One of the senior midwives was conducting some research into how primary healthcare (PHC) is delivered at Chikankata in a bid to encourage more government funding for primary healthcare. PHC is a crucial part of what Chikankata does in the community so I was more than happy to help a little by providing ideas and proof-reading the plans for expanding the ongoing PHC work. I also wrote up a piece on potential screening schemes that Chikankata may be able to start up, including cervical screening, schistosomiasis screening and trachoma screening. Currently these screening programmes are provided by visiting NGO teams, but following assessment of the cost of screening equipment, the delivery of these screening programmes could be more efficient and effective if delivered by the hospital. I am glad I could contribute something towards the long term goals of Chikankata by being involved in this research.

I was also able to spend time with the hospital Chaplain/Social Worker, Major Namchilla who does a lot of work to provide social support to patients. Her work varies from identifying patients who may need donated clothing or some financial support to pay for treatment, to going around the wards and praying with patients. I had the privilege of also visiting a support group she runs for children with disabilities and their mothers – I enjoyed playing with the kids and was also asked to pray with the group. I also went on a HARD (HIV & AIDS response department) outreach trip as part of the Community Orphan Support Project. The main aims of this project are to empower guardians to look after the orphans under their care (e.g. by teaching them entrepreneurial skills) and also providing psychosocial support to orphans. It was fantastic to see the social side of what Chikankata does to supplement the medical care that they provide.

Outside the hospital, I was also able to visit the local secondary school with one Chikankata doctor as she spoke at the school's careers day. It was inspiring to hear talks about the importance of education and see the enthusiastic school kids respond so positively.

Outside work

As all the elective students lived together, we got to know each other well, cooked together almost every night, had movie nights, games nights, a kids party themed day, even exercised together. The area around the mission is fantastic for walks – there's Chikankata dam, a great place to watch the sunset, lots of hills for hiking (Mabwetuba is a particularly popular one which I went up twice with some of the other elective students). I also enjoyed attending the nursing and biomedical science students' fellowship every Sunday evening in the Hospital Chapel and it was always so encouraging to hear their testimonies and their harmonious singing! Many evenings, we went for dinner at the Hospital Administrator, Carl Wardley's house as he had an open-door-policy for elective students. Carl and his family were very warm and welcoming and their hospitality was I am so grateful for their hospitality during my stay at Chikankata. Carl also gave us good tips on places that were a must to visit near Chikankata!

Chikankata is perfectly situated in the Southern Province, making it relatively easy to visit Livingstone (a 5 hour coach ride from Mazabuka) – I went with a couple of other elective students and saw Mosi-oa-Tunya (or Victoria Falls, so named by the Scottish missionary doctor and explorer Dr David Livingstone) I was also able to spend a weekend camping at Lake Kariba, Africa's largest man-made lake, which was just a 3-4 hour journey away from Chikankata.

Advice to students considering a mission hospital

My top tips would be
1. Don't be afraid to travel somewhere by yourself, even if you've never done it before – my trip to Zambia was my first time travelling anywhere outside the UK by myself. However, as long as you're sensible about staying safe, travelling alone abroad is not too dissimilar from travelling alone in the UK (in fact, I probably felt safer in Chikankata than some parts of London). It's also a good idea to check if there will be other elective students around at the same time as you – meeting new people is fun and my elective experience was made all the better by the friends I made at Chikankata. Even if you're the only elective student there, it is highly likely you will be well looked after by everyone at the mission!
2. Read lots of elective reports and make sure you're prepared mentally for what to expect. Reading reports will also give you an idea of whether working in a resource-poor setting is something you would enjoy or whether a different experience might be better for you.
3. Immerse yourself in the culture – make friends, get to know the locals, accept hospitality. In a mission, there will be lots going on besides hospital work, so get involved!

Conclusion

I had an incredible and unforgettable time at Chikankata and cannot recommend it highly enough! Not only was I able to see medicine practised in a completely different setting from what I'm used to and experience a different culture, but I had a lot of fun, built confidence in my clinical ability and learnt so much. Stepping outside my comfort zone and travelling alone to Chikankata was one of the best decisions I've made and I have no regrets in choosing to do my elective there. I hope to return and am now very strongly considering working in a mission hospital, short or long term, at some point in the future.

I would like to thank EMMS International, Beit Trust and Gilchrist Educational Fund – this amazing elective would not have been possible without their generous grants.

Cost breakdown:

• Flights - £530
• Accommodation - £500
• Local transport (including airport transfer) - £200
• Food - £150
• Internet and mobile airtime - £50
• Anti-malarial prophylaxis (doxycycline) - £20