I just recently finished, Better, by Atul Gawande, a general surgeon at the Brigham and Women’s Hospital in Boston. The book presents Western Medicine as a field which has made enormous progress in patient care over the past century (and even the past several decades), whether it be in reducing maternal mortality rates through anesthesia and Cesarian sections, or reducing mortality rates in wounded soldiers through army forward surgical teams. But the book also exposes the weaknesses of medicine. It sets out to try and resolve the problem of how to continue to improve performance in medicine given all of its constraints: limited resources, uncertainty in diagnosis and treatment, limited control over the outcome of a particular patient’s case, the constant threat of malpractice suits, etc. The book is split into three major sections, “Diligence”, “Doing Right”, and “Ingenuity”, representing Gawande’s suggestions for improving performance. In his view, these are three essential ingredients for success and improvement in medicine. In each of these three sections, Gawande pulls in examples from different success stories displaying one of these three qualities. One of the most striking examples Gawande uses, of how “diligence” is key in improving performance in healthcare, is in his examination of the drastic decrease in mortality rates in wounded soldiers over the past couple of decades. During the Vietnam War and “even the 1990-1991 Persian Gulf War, mortality rates for the battle injured remained at 24 percent. Our technology to save the wounded seemed to have barely kept up with the technology inflicting the wounds”(pp.52). However, it wasn’t until the wars in Iraq and Afghanistan that we saw a “marked, indeed historic, reduction in the lethality of battle wounds….just 10 percent of the wounded American soldiers have died” (p. 53). Gawande attributes this decrease in mortality not to new treatments and technologies but to the efforts on the part of military doctors to “make a science of performance, to investigate and improve how well they use the knowledge and technologies they already have at hand” (56). Two major steps military doctors took to help decrease soldier deaths were the enforcement of protective “Kevlar vests” to protect the core from blasts,etc., and also in the implementation of “Forward Surgical Teams”, which are “small teams, consisting of just twenty people: three general surgeons, one orthopedic surgeon, two nurse anesthetists, three nurses, plus medics and other support personnel” that follow the troops “right out onto the battlefield” (p.57). Basically, through self-evaluation, military doctors were able to understand that the time it took to transport a wounded soldier from the battlefield to a medical facility was often too long to save his life, so they adapted their system in order to try to save more people. The book is filled with similar examples of efforts at self-analysis and adaptation in medicine that have significantly improved results in patient care.
So anyway, after reading this book, I got to thinking more about healthcare in Kola. There are some glaring constraints: there is a small health clinic with very few materials and only two official personnel: a nurse and a midwife. I’m also often turned off by the way the nurse speaks with his patients–I often find him condescending and unwelcoming. I also know he tends to overprescribe medicine. Things are not run perfectly. However, the effort to self-examine, and the will to improve is nonetheless there, and I am in general really impressed by it. Last year, Unicef helped fund relais trainings throughout Mali. Relais are basically community volunteers who act as messengers between the community run clinics and the surrounding villages. Their role is to get people to use the clinics more. In theory, they educate people about vaccinations, pre-natal consultations, the advantages of giving birth at the health center, and inform the clinic about the needs of the people. So there are eleven relais who act as messengers between Kola and the surrounding villages that the clinic serves. For the past couple of months the relais have been making trips to each of these surrounding villages to meet with community members and ask them what their issues are with the health clinic. In otherwords, trying to better understand what may be preventing the villagers from using the clinic for births or for vaccinations. The point of these troubleshooting sessions is to get the clinic to better respond to the communities’ needs and to further community members’ understanding of how the clinic works and the resources available there. Not all of the relais are motivated, but in general, I find this sort of initiative really impressive and progressive. During one of these meetings, a villager mentioned that one of the major drawbacks to giving birth at the health center is that there is no food for the patient. The patient’s relative or in-law is supposed to come along with her with their own food and prepare it for the recovering mother. As a means of solving this issue, the relais suggested that people from the surrounding villages find a host family in Kola (where the clinic is) who can cook for them in case they come in and use the clinic. This issue has also gotten the relais interested in building a cooking hut and buying cooking materials forthe clinic. Two simple solutions that will hopefully encourage people to come to the clinic. Way to take initiative, Kola!
So then a couple of days ago I decided to assist Kola’s midwife with a birth. I know very little about birthing, so I mainly just stood there and felt my legs become weaker and weaker as I witnessed a fairly difficult birth. It was a fourteen year old Fulani girl. Her age puts her in the “at risk” category. I know nothing about birthing, but I do know that tapping and pushing on the stomach is generally not a recommended thing to do. So as the midwife tapped and pushed the girls stomach to try to force the baby out, I was a little concerned, but at the same time, I did not feel like I was in a position to intervene. The midwife kept complaining to me that the girl was too small as she pushed on the girls stomach. I will skip the gory details, but the baby finally came out, wide-eyed and crying and energetic , and it made me wonder if maybe Djenebu (the midwife) had been doing the right thing afterall. Because there are so few materials and personnel at hand in case something goes wrong, births cannot be prolonged affairs. Again, I know very little about this, but I assume that the midwife was using her best judgement when she was somewhat forcibly pushing the girl’s stomach. She probably figured that it was more risky for the baby to just hang out in there than to force it out. And voila, it all seemed to work out in the end!
And as for the nurse’s prescribing too many medications, maybe he’s doing it because it is not always easy to diagnose patients and he figures it is better to cover his bases rather than try to treat the wrong illness.