Please see Part 1 to read more about Dr. Grech’s pre-trip preparations and experiences working in a busy, remote pediatrics clinic.
After seeing what must have amounted to hundreds of children over the preceding days, our Madagascan medical mission with International Medical Relief (IMR) was due to take a significant turn, with a dramatic change in our environment and a further challenge to our clinical abilities. This part of the mission had not been widely known to the whole team until the night before this final clinic and came as somewhat of a surprise to me.
Keen to experience different clinical settings within the remit of the mission, the next unique clinical environment was to be a remote prison in Toamasina. This mixed gender facility housed thousands of people and was structured (to the visiting eye) as a closed village, set around a large courtyard. Security was strict, as expected: photography was prohibited and armed guards accompanied mission members throughout the clinic session.
Toasamina, on the eastern coast of Madagascar. (Google Maps)
Limited shade from the blistering sun struck me as a significant challenge for those living here – the midday sun scorched the earth, with large central areas having little or no structures to provide shade. This space did serve a purpose apart from providing an open area with the possibility for exercise, it also ensured a large part of the prison was well ventilated. We were told by local staff that there was no tuberculosis within the prison, although we were soon faced with many patients reporting weight loss, fevers, and lymphadenopathy. Needless to say, all care delivered from our end was with appropriate personal protective equipment in use.
Medical care was reportedly inaccessible within the prison, with no healthcare or referral system in place for inmates to use or seek advice from. Residents also reported longstanding suboptimal control of chronic health conditions due to poor access to medications. Although I thought of myself primarily as a pediatric physician on this mission, I hadn’t realized until this point that I was also the only male healthcare provider. With this realization in mind and due to a mix of cultural and patient preferences, all male genitourinary complaints were triaged and assigned exclusively to me. Of the forty men I reviewed, a varied case mix presented itself. I encountered a large number of presumed sexually transmitted infections, presenting as typical symptoms of dysuria, purulent discharge, or genital ulcerations. In addition, I noted large numbers of perineal cutaneous ascariasis, likely secondary to poor environmental conditions and scarce availability of hygiene measures. Other mundane symptoms also made their way to me, with chronic cough and lymphadenopathy among the most common.
One young man in his thirties reported scrotal swelling of spontaneous onset over the preceding two months. Clinical examination revealed a large, hard, tense scrotum, with patchy discoloration of the left hemiscrotum and episodic localized discomfort. Unable to palpate above this solid, non-transilluminable mass further and with the systemic symptoms including weight loss, I feared a malignant cause. Healthcare even for this possible life-changing diagnosis was close to impossible to access according to staff – he would need to wait until he was released.
One older man in his seventies reported worsening groin swelling over recent weeks, worse at the end of the day and causing discomfort when trying to sleep. Examination once again revealed a large, swollen scrotum, this time with features concerning for a significant inguinoscrotal hernia. As this was still fully reducible, our most pragmatic solution was to educate about methods to limit herniation such as reducing straining and lifting and red flag signs of incarceration or strangulation until this patient could seek corrective surgery on his release. A temporary measure to reduce symptoms until potential surgery would have been use of a truss belt - however, no such device was readily available. Our subsequent search for suitable improvised alternatives was quickly shut down by facility staff, as we were informed that residents were not permitted any fabric capable of being used as a ligature. However, our suggestion to use tighter (or even double-layered) underwear to contain the patient’s groin swelling was well-received.
A further case which may have merited urgent surgical intervention in a more developed healthcare system was one of suspected septic arthritis of the knee. A young man presented with a warm and swollen left knee demonstrating clear signs of a tense effusion, with overlying erythema, limited range of movement, and pain on both active and passive mobilization of the joint. Attempts to alleviate this were made with oral analgesic agents and stat intramuscular antibiotic administration, together with an attempt at joint aspiration. An amount of purulent fluid was removed via landmark-based aspiration of the knee compartments and once more urgent medical care suggested. We knew however that antibiotics were in short supply and that rest, compression, and elevation were likely the most achievable level of care this patient would receive, barring access to a tertiary healthcare facility.
Many patients complained of chronic coughs. Although possibly related to their frequent smoking of tobacco, this was nevertheless concerning in an environment with such potential for tuberculosis exposure and dissemination. We raised this as a concern to the facility’s authorities and kept our own mission records for later data keeping and reporting.
Overcrowding in such environments evidently presents an epidemiological risk of rapid and pervasive spread of communicable disease. Undoubtedly, preventative measures and prompt treatments of infections could go a long way towards limiting contagion even in such a challenging context. However, as we soon discovered, the ability of both staff and inmates to utilize methods for any of these strategies was clearly restricted. We were left with a sense of demoralization, having merely performed what we couldn’t help but feel was damage control medicine.
To add to this sentiment as we left the prison for our next clinic location, the overwhelming poverty across the developing Madagascan nation was evident. For although we were told repeatedly that healthcare access for prison residents would improve significantly after their release, none of those we reviewed during our prison clinic reported being able to afford it.
The Madagascan sun setting on our mission experience (Jamie Grech)
Mission Conclusions
I often reflect upon the short-term good the mission may have had, but dwell on the idea that a far greater good can only be achieved through sustainable endeavours such as long-term education and preventative medicine practices that are rare in such resource-poor environments. Considering the great variations in healthcare access across the world and especially in developing countries, the realities and complexities of health inequality can become overwhelming to a budding physician. I frequently find myself hoping to contribute to an idea of larger-scale, change-generating global health initiatives, and aspire to one day do so – delivery of healthcare education designed specifically for austere or resource-poor environments is an evolving way of doing this, building upon the sustainable efforts I witnessed on the IMR mission.