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Tucked away in the heart of sub-Saharan Africa lies Zambia, one of the continent's best kept secrets. Formerly known as Northern Rhodesia, Zambia was a British Protectorate until 1964 when it gained independence. It shares a border with eight other African countries, many with longstanding internal conflicts. Despite this, Zambia enjoys relative peace with a functioning democracy, free elections and status as 2012 African Cup of Nations football champions! The country is landlocked but by no means lacking water with wetlands covering nearly 20% of the terrain. In fact, Zambia derives its name from the mighty Zambezi River which arises in the North-Western Province and empties into the Indian Ocean. As a result, outdoor activities abound including kayaking, tiger fishing and spectacular wildlife viewing. This is the tropics, relatively underpopulated, with vast swaths of fertile land seemingly untouched since the dawn of time.
Zambia unfortunately also lies at the heart of the HIV pandemic. It has an HIV prevalence of 13.5%, among the highest in the world.1 The situation has improved with the availability of highly active antiretroviral therapy but HIV-associated diseases continue to overwhelm the health system across every patient population. Until very recently, the University of Zambia School of Medicine was the only medical school in the country with approximately 80 graduates per year. Of the 1327 healthcare facilities in Zambia, 85% are government-run facilities, while 9% are private sector facilities and 6% are religious affiliated (mission) facilities. The three levels of public health facilities are hospitals, health centres and health posts; the hospitals are divided into primary (district), secondary (provincial) and tertiary (central) facilities.2
There are a number of strains on the Zambian healthcare system. It is estimated that the country has less than half the number of required healthcare workers and only a third of the recommended number of doctors to provide the required level of treatment. There continues to be a problem with physician retention due to emigration. The estimated number of doctors trained in Zambia and practising in the USA and Canada in 2002–2003 was equal to 11% of those working in Zambia.3 To combat this shortage, particularly in rural areas, the country relies on paraprofessionals in the form of clinical officers and community health workers who form the backbone of the healthcare delivery. In many communities, traditional healers are still the first point of contact for medical conditions. It is common to receive questions on the role of witchcraft when counselling patients with epilepsy.
Presently, we are the only two neurologists, both foreign trained, in this nation of approximately 13 million people. If this ratio seems overwhelming, at times it can be. As a result, our focus is not to hold outpatient clinics each day with an endless stream of patients lining the hallways. This is not an efficient use of time or resources. Instead, our focus has been on training those on the frontlines on how to treat the most commonly encountered neurological conditions.
We are fortunate to be based at the University Teaching Hospital in Lusaka, the country's only tertiary care facility with a number of available resources. University Teaching Hospital has both a CT and MRI scanner, costing approximately US $170 and $270 per scan, respectively. There is a cost sharing system, such that patients pay a share of these studies based on their level of income. Through the efforts of the World Federation of Neurology and the US National Institutes of Health, we also have a newly established neurophysiology laboratory with EEG and EMG/NCS equipment. The full complement of laboratory studies is not available and there are frequent technological failures that are anticipated in a resource limited setting. Luckily, a good clinical history and the elegance of the neurological exam can still often establish a diagnosis without an over-reliance on technology. As a result, there are times when we feel a kindred spirit with the giants of the field, like Wernicke, Charcot and Babinski who practised with similar (actually much greater) diagnostic limitations.
This is truly a frontier of neurological disease. The disease burden is enormous with a vast spectrum of neuropathology ripe for study. There are days where it seems that every patient encounter could be a case report: kerosene ingestion presenting as a pure motor neuropathy, a family with progressive ataxia and an HIV patient with four pathogens in the cerebrospinal fluid (CSF). The patient population spans the fields of tropical neurology, neuro-infectious diseases, as well as common neurological conditions. A typical week may include neurocysticercosis, tetanus, cryptococcal meningitis, subacute combined degeneration and Parkinson's disease. There is heartbreak such as helping a family cope with aphasia in the breadwinner who has suffered a stroke. There is the gratification of successfully treating someone with epilepsy who was initially felt to be ‘possessed by spirits’ and is subsequently able to return to work. There is a high level of stigma in people living with epilepsy in Zambia. Much of this has to do with the false belief that it is a contagious condition. As a consequence, people living with epilepsy are likely to be poorer and have a lower social status.4 Patients frequently make the journey by bus over days and hundreds of kilometres to have a consultation. Mentally, it helps to focus on the victories and to take pride in any achievement that helps to improve the overall system.
No two days are ever the same. One week may involve lecturing to the medical students about neuropathology, seeing both inpatient and outpatient consultations, meeting with a non-governmental organisation about procuring the proper tubes for CSF collection, and buying protective bars for the entrance to the neurophysiology laboratory to prevent against theft. There is no formal way to gain all the skills needed to function in this setting except for practical experience. It is amusing to hear our friends and colleagues from back home ask if neurology is too specialised a field for Zambia, as if neurological diseases only exist in certain areas of the world. It is always entertaining to host visiting neurologists from resource rich settings and gauge their reactions. Since 2004, the World Federation of Neurology has sponsored the Visiting Professor Program in Zambia, resulting in neurologists from around the world spending 1 month providing formal lectures and clinical teaching to students at the University of Zambia School of Medicine. Many are shocked by the neurological disease burden and the diagnostic limitations. However, almost all are exhilarated by the possibilities of making a difference.
We are both heavily involved in research activities with partnering institutions from all over the world. Research remains a vital part of improving delivery of neurological services. It is essential to establish the prevalence of conditions such as epilepsy, stroke and central nervous system opportunistic infections, so that the Ministry of Health knows best how to spend its limited resources while maximising impact. The research possibilities are endless, as almost any question is waiting to be answered. Some of our ongoing projects include the Parkinson's genetics, molecular diagnostics of CSF in HIV and epilepsy-associated stigma in rural Zambia.
Like many settings, the most gratifying moments come from patient care. The benefits of successfully treating a patient, in many ways, are more tangible than in the West because so many more people rely on the health of a single individual. Gratification also comes in less traditional ways. One memorable moment was obtaining a wheelchair from a non-governmental organisation for a man with paraplegia from spinal tuberculosis, whose wife carried him on her back to appointments. The cultural interpretations of neurological diseases are also fascinating. In the native language of Tonga, spoken mainly in the Southern Province, one phrase for epilepsy is ‘citambilwi abana’. Its literal translation is ‘that which is not talked about in the presence of children’. There is something very special about taking part in the early stages of building a neurological community. There is a tremendous pool of young, talented Zambian physicians who would love to become neurologists if the opportunity was available. The establishment of a neurology training programme is currently our highest priority.
Beyond improving neurological care, there are numerous other benefits from working in Zambia including its stunning natural beauty and the warm and accepting Zambian people. A visit to this area is incomplete without a trip to Victoria Falls. Rafting down the Zambezi River is another popular option for the more adventurous. There are numerous large national parks where one may be treated to a wildebeest migration, a pride of lions feasting on a Cape Buffalo or an African Fish Eagle trolling a riverbank. Most illuminating of all is a drive through rural Zambia where one can appreciate diverse communities that inhabit its countryside. It is exhilarating to live in a country that is starting to realise its potential in terms of economic development, education and health. Zambia still has much to teach us and the world about neurological diseases. This is why we have chosen to pursue our careers on this neurological frontier.
National flag of Zambia
Masters of medicine (internal medicine) trainees
Outpatient neurology clinic
Centre of Excellence in Neurosciences
Inpatient neurology rounds
Bedside teaching
7th year medical students
Acknowledgments
The authors thank Dr Laston Chikoya for his valuable input towards the manuscript. All of the individuals pictured in the photos provided consent for use of the photos in publication.
Footnotes
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
Funding OKS is funded by NIH grant R21 NS073509 and the American Academy of Neurology Clinical Research Training Fellowship. He also received support from Fogarty International Clinical Research Fellows Program.
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