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1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn 1993 chương trình viện trợ của canada ở angola phải đối mặt với những vấn đề lớn
Canadian aid program in Canadian aid prograin in Angola faces huge problems Frank Timmermans, MB, BS, FRCSC, FACS A s you walk up the wellworn path through the open African field, it becomes obvious that the six-storey building at the top of the hill is a hospital Used medical supplies, gloves, broken syringes and the occasional medical record litter the field Travel the same path at night, and you hear rats scatter for their holes In the driveway at the hospital's front door stands a large, open garbage container overflowing with waste Small boys with sticks can often be seen busily sorting through the garbage, seeking interesting prizes such as catheter bags and gloves Closer to the hospital, rubbish can be seen hanging from the wide window ledges - a clue to one of the more common disposal methods And in a grove of Australian gum trees beside the hospital, a dilapidated yellow stucco building is often the source of the eerie wailing that means death This is the morgue I went to Lubango, Angola, in October 1991 to participate in a Canadian aid project that was designed to train local physicians to be good generalists, with skills in surgery, obstetrics, medicine and community medicine Lubango, a city in the southern part of Angola, has about 180 000 residents The project was the combined formed the hub of the academic program Angola was in considerable turmoil during our visit, but at least there was a cease-fire in the 16-year civil war while preparations were being made for a supervised election The MPLA, a communist party with strong ties to Cuba and the former Soviet Union, was in power The opposition was provided by UNITA, a guerrilla group backed by the United States and South Africa (Since my visit, elections have returned the MPLA to power Although they were deemed fair, and UNITA has enough seats to provide effective opposition, its leader is unhappy with the results and there is now a real threat of renewed guerrilla warfare.) In 1991, the streets were safer than they had been in years, but the countryside, littered with countless unexploded bombs and land mines, continued to take its toll Lubango was one of the country's more secure areas One of the most striking things about Angola, and something it shares with many developing countries, is the authoritarian, obstructionist bureaucracy Third World bureaucrats often see their jobs not as positions of responsibility or public service, but as positions through which power, no matter how fickle or frivolous, must be exercised Contracts are often worthless, appointments and timetables impossible, and successful, long-term planning rare Many people in these countries accept such abuses: they expect nepotism, kickbacks, featherbedding and theft to be part of the system, and are usually right This means that something as simple as buying a bicycle for a local church is a transaction fraught with difficulty, and that bringing a shipping container into the country is nearly impossible If it somehow passes through the bureaucracy, it almost certainly effort of various nongovernment organizations The Canadians were allocated a ward in the Soviet-built Central Hospital and it, along with the Outpatient Department and several outreach clinics, Frank Timmermans is a general surgeon practising in Whitehorse, Yukon MARCH 15, 1993 An OR in Angola: The conditions were appalling CAN MED ASSOC J 1993; 148 (6) 1007 will not escape the thieves In this situation, the foreigner or aid worker who has only average perseverance can be expected to throw up his arms in despair and leave, vowing that all aid is a waste! There are, however, local people who are honest and anxious to see change and improvement in society They work against incredible odds The project director Angola's only otolaryngologist and the staff physicians seemed to have endless patience and perseverance as they waded through the bureaucratic and political quagmire Such patience had to be in abundant supply for those of us used to Western democratic institutions and who were now trying to work in Angola's health care system The six-floor Central Hospital in Lubango is vast and empty The wide hallways are lined and tiled with marble slabs from the coast; the style is distinctly Soviet I was told that people avoid the hospital; once inside, it was not difficult to see why The smell of urine is everywhere, but is particularly overwhelming in the stairwells The Emergency Department is often empty There is a treatment room with a bare metal operating table, several other completely empty rooms of indeterminate purpose, as well as a six-bed ward The ward smells There is dried blood and vomit on the floors, and the mattresses are more stained and dirty than can be imagined: it takes a strong stomach to examine a patient on one of these beds There are no pillows, and no linen of any kind Sterility, let alone cleanliness, is unheard of here The only medical equipment is a few random packets of sutures in a plastic bag and some basic instruments in a boiler The staff, in contrast, are wonderfully turned out in fresh white starched and ironed uniforms Such paradoxes are common and always striking There was never any water available above the bottom floor, and the electrical supply was often interrupted There were two new Soviet diesel generators, but the equipment and experts needed to hook them up were not available Water arrived on the fourth floor through a hose passed up the outside of the building, through the offices and down the hallways, where it was used to fill drums on the ward That water was used for drinking, occasional toilet flushing, and sometimes to wash hands On the teaching unit, conditions were equally primitive The WTT dt, The scene outside the front door of Central Hospital 1010 CAN MED ASSOC J 1993; 148 (6) windows were unscreened and flies were everywhere; at night they were replaced by malaria-carrying mosquitoes There were the ubiquitous dry, and sometimes not so dry, secretions on the floors Patients often had stale food beside their beds and the smell of urine and vomit were at first overpowering After month or so the smells no longer seemed so pervasive, and I am sure that after months they would have seemed quite normal The supply of drugs and equipment on the wards was pitifully small, but far in excess of what was available in the rest of the hospital All plastic syringes and needles were reused after boiling Even with the high incidence of HIV disease, no effort was made to rinse them with bleach and the hazard faced by patients and nurses was clear Eventually we managed to secure a bottle of household bleach from Namibia so that the syringes could be rinsed before being disassembled and boiled Even that effort will probably not last No narcotics were available - apparently they could not be imported into the country The management of pain, particularly for surgery or changing burn dressings, was dreadfully inadequate The aid project used a general operating suite; a dedicated operating room in which better standards could be set had been promised but had not yet materialized because of the usual bureaucratic hurdles and power struggles Operating conditions were appalling Water and electricity supplies were often interrupted The rooms were filthy The corrugations in the foot pedal of the primitive cautery device were obliterated by dried blood Instruments were selected from bulk tins in which they had been piled at random We wore the same gowns for the whole list of patients and the operating tablesLE 15 MARS 1993 two to a room - were either bare metal or covered with a ragged gown, one too ragged to wear The project had provided its own linen, but this had gone the way of all such things in Angola, and probably ended up on the black market Patients were walked in to the operating room and when they arrived for surgery were naked, or nearly naked; it was clear that surgery was a truly frightening event After surgery, they were wheeled out on a bare tin trolley to the "recovery room," where they would be left alone on filthy mattresses to recover without observation, oxygen, suction or any of the basic things a Canadian doctor takes for granted There was one Russian anesthetist at the hospital, although nurse-anesthetists did most of the work No premedications were used, and only three intravenous drugs - diazepam, sodium pentothal and ketamine hydrochloride - were used There was no oxygen or nitrous oxide For infants, a halothane-soaked gauze was often held over the face to augment anesthesia Unfortunately, it seemed to have much the same effect on surgeons as infants! No anesthetic record was kept and no vital signs were taken The patients were not accompanied by their records and wore no identification The potential for a wrong operation was ever present - indeed, I can tell a personal story of such a disaster The infection rate after surgery was so high that I believed surgery should only be performed to avoid clear and imminent danger Simple procedures could turn into nightmares soon after the operation, and this fact proved almost unbearable for a fastidious surgeon used to Canadian standards That any patient here could successfully undergo surgery and live through its sequelae is a tribute to man's ability to survive If conditions at the Central MARCH 15, 1993 Hospital were bad, those at the Maternity Hospital in Lubango were even worse Its reputation for maternal and infant death made it an object of fear The first two women I saw in consultation were completely naked when brought into the room They lay on a filthy tin table The only light was provided by the window There was no speculum; I was grateful for the gloves I had brought with me The first woman had a massive fixed carcinoma of the cervix, the second a two-finger vesicovaginal fistula There was no sink, no water, no way to clean up The women left as they had come, somehow preserving their dignity Hospital care in the two Lubango hospitals was much the same as in those in the capital, Luanda It is the worst care I have seen in any Third World country Even allowing for the shortages of equipment and supplies, it was much worse than need be Simple reorganization, some attempt at cleanliness, and'even a slight reduction in political and bureaucratic obfuscation could make an enormous difference I believe the situation reflects the government's and health authorities' monumental lack of interest in improving the standard and availability of health services in Angola Given that lack of interest, how could even a modest foreign-aid program hope to succeed? The Lubango project was beset with difflculties from the start The Angolan government had ignored its previous commitments, particularly its promise to provide some funding There were endless difflculties at the Central Hospital, which seemed to revolve around resentment of the Canadians because they seemed to have access to more equipment and drugs and better housing and transport The first group of student interns complained that they had no housing or transport They had been provided with hotel ac- commodation that was a 0-minute walk from the hospital Often, they simply did not turn up for scheduled classes They were incredulous when I and other physicians told them that in Canada, most interns find their own housing and transport and work much longer hours Rather than considering themselves postgraduate students, they viewed their appointments in the same way that Angolan civil servants seem to regard theirs The program was seen as a step up the ladder, and therefore should be accompanied by more pay, privileges and perks and less responsibility and work Even mild criticism was taken as a personal affront, and all but one of the six students resigned shortly after the course started Despite these problems, new students have been recruited those with church connections and a more altruistic outlook seemed ideal - and the aid project limps on Who can argue with the project's goal of training students in their home countries under the circumstances they will encounter once they graduate? For me, the Lubango project again brought home very strongly the difficulties faced by people in the Third World They cannot improve their own lot simply by relying on haphazard handouts from the rest of the world First, they have to overcome the internal power struggles that begin at the top and always have as their aim the self-aggrandizement and enrichment of one group or person The connection between true cooperation and a healthy successful society needs to be made Trying to build a health care system in Angola is a daunting task Ordinary Angolans, and especially the long-suffering women and children, are probably justified in viewing illness with a stoic fatalism, and the general situation with a sense of resignation and hopelessness.CAN MED ASSOC J 1993; 148 (6) 1011