We Have Changed

The shortage of doctors is not just an African phenomenon, it is a worldwide phenomenon. In the United States, for example, new physicians avoid primary care medicine like the plague. Older physicians burn out quickly, and retire at a relatively young age. Medical students clamor for dermatology residencies like the world truly needed a disproportinate number of skin doctors. And yet waiting rooms are teaming with the uninsured and forgotten. And these needs pale in comparison to the developing world. Why?
While doctors and other health care professionals cannot complain about salary in the developed world (but do, nonetheless), there is much more to job satisfaction than money. Long hours can preclude family time, personal growth, sanity. While caring for the sick is a privledge, it's not easy, and it has its toll.
So what about a new model for health care provision? Maybe the majority of health care doesn't need to be provided by doctors and nurses. Maybe those who begin at one level- say an entry level medical assistant- could earn time towards nursing or medical school, and that doctors could move from clinical years to teaching years or innovation/research time or foreign development or medical business or public health or whatever. Maybe a lifetime in just one medical clinic for a doctor is not a realistic expectation anymore. Neither is a clinic staffed by mostly doctors. Medical technicians, physicians assistants (all with the incentives of moving up the ladder of medical professionals) may make more staffing sense. In Zambia, much of the care is provided by nonphysicans. But they're under tremendous stress, without the possibility of promotion. That needs to change. Something needs to change.

 
 
Aka Kalema (pictured on the right) is a clinical officer at the Nansenga Rural Health Centre, about two hours drive from Lusaka. As rural outposts go, it is not in a remote area, but far enough removed from the city to mean no physicians are available. Clinical officers are the equivalent of physician's assistants in the United States, but given the lack of doctors in Zambia, their role is greatly expanded. Aka is the highest level of health care provider available in a large network of rural villages surrounding the clinic. He sees children, adults, and assists with deliveries when birth attendants are not available. Except for two weeks out of the year, he is essentially on-call 24 hours a day. Officially the clinic is open 8 am to 5pm, but once or twice a night Aka may be awoken from his nearby living quarters to see patients. Medications can be in short supply. Aka has an impressive knowledge of medicine- but then again, he must, where there are no doctors. In addition to his clinic duties, he is also administrator, statistician and public relations for the small but busy clinic. While he describes satisfaction with helping the people of his community, he admits to fatigue and stress. Like anyone, he yearns for growth, and would like to go to medical school and be a doctor some day. But his three years of training for work as a clinical officer, as well as his years of experience, count for nothing when applying to the few competitive spots for medical school in Zambia. In addition, the financial burdens of medical school are great. And yet, realistically, he cannot leave- his training is not recognized in neighboring African countries or overseas in the UK or US.
A great deal of care in Zambia and the rest of Africa is provided by such hard-working non-physician providers. "Task-shifting", that is, the shifting of tasks in the health field from physicians to non-physicians such as Aka, is a key element of providing health care where there are not enough doctors and nurses. But this shifting means a heavy burden is placed on their shoulders. In some remote rural areas, in fact, the "sweeper"- the janitor, is the only one available to provide care.