I spent this week visiting rural health facilities in a nearby district outside of Lusaka. Traveling throughout Chongwe was my first small look into the real Zambia. Driving long empty, winding roads crossing through kilometers and kilometers of red dry earth, trees and mountains you can’t help but be struck by how much space is here. Sporadic small villages occasionally cropped up as small collections of houses and huts, off the beaten path and difficult to reach by car. The long drives are otherwise broken up by individuals biking or walking alongside the road, transporting charcoal or making their way between locations. I often wonder their destination, especially for the pairs of unattended walking young children, as the trip from one settlement to another sign of civilization ranges from 10 to 20 minutes by speeding car. More developed areas held stretches of connected cement shacks housing convenience stores, bars, and newsstands that offer those commodities you can reliably procure regardless of your location…what I’d call the essentials: water, talk time for the pay-as-you-go cell phones, soda, chips, eggs, alcohol, rice, nshima and maybe chicken.
The health centers serving these populations are entirely managed by a nurse and one or two trained staff. Manuals and paperwork haphazardly occupy tables and medical record shelves hold rows of tattered composition notebooks, each assigned to a patient, that contain scribbled patient information. Record keeping, drug ordering, stock monitoring are all done by hand in this paper and pencil system.
The purposes of our team’s visits were to evaluate the system for ordering and receiving various drugs, to review their adherence to protocol for recording and requesting medicine, to make recommendations for improvements and to get a sense for the challenges facing the health center worker. The challenges are many. Each nurse (or otherwise trained worker) must maintain handwritten records of drug use, pencil in a report to request drugs from the district, take unreliable public transport to the district office to submit their request, go home, and return by bus once again to collect their commodities so the health center can have stock. When a worker is gone on these trips or on leave, work often stops. Motorbikes are sometimes made available to health centers but then there is no gas, or no money for gas. They are in need of repair, or carrying drugs while wheeling down unreliable rocky roads is a challenge in itself. When dirt roads are washed out in the rainy season, receiving commodities becomes complicated, if not impossible.
Walking into each health facility and past long queues of women, crying babies, men and children, reinvigorated my strong and lifelong desire for clinical skills that I’d hoped had been previously quelled. Prior urges to study medicine or nursing I thought had been muted when I discovered the population level intervention opportunities available through a focus in public health. Since being here, I’ve been heavily revisiting the idea of enrolling in a nursing program after the MPH, or finding another way to receive clinical training. The idea of working on the bigger picture, designing or managing programs to improve access to health care, without being able to intervene on the individual level, through diagnosis or critical care, where needed, and have an impact on the ground strikes me as irresponsible, or more likely, puts me in a helpless, onlooking position that I am in no way comfortable idly assuming… at least not as long as I can still learn or see or use my hands and feet, maybe even just my teeth. More important than me or my desires, this work is just so needed.