Mbomo is a district in the Cuvette-Ouest Region in the western part of the Republic of the Congo. Judging from statistics from the Unicef vaccination programme and local demographic researchers, the Mbomo district had a population of approximately 9,347 inhabitants at the start of 2016. As Mbomo covers quite a vast area, this corresponds to a very low population density. The landscape mainly consists of dense jungle, and spread out in the jungle of the Mbomo district are numerous small primitive villages.
In this region of the Republic of the Congo also lies Odzala-Kokoua National Park (PNOK; Parc Nationale Odzala-Kokoua). This nature reserve is home to some of Africa’s most renowned inhabitants, such as elephants, hyenas, buffalos and silverback gorillas. The international non-profit organisation African Parks is in charge of preserving Odzala-Kokoua National Park and protecting its wildlife. Armed soldiers called eco-guards patrol the park in an attempt to counter poaching.
African Parks has a camp at the main village of Mbomo, from where these jungle expeditions are organised and coordinated. But African Parks does far more than combat poaching. In addition to the soldiers of the eco-guard, the camp at Mbomo is – amongst others – home to primatologists, veterinarians, ecologists, biologists, medical professionals, agriculturists and experts on community development.
Medical care is underdeveloped in the area, and medical facilities and resources are scarce. The most pressing forms of morbidity in the region are malaria, diarrhoea and acute respiratory infections. Other prevalent forms of morbidity include sexually transmittable diseases (such as HIV, gonorrhoea, syphilis and chlamydia), parasitic infections, infected wounds, river blindness and leprosy. In the early 2000s, an Ebola epidemic claimed many lives in the region. The risk of Ebola re-emerging is ever-present and a credible threat. There are also concerns of a more sociological and anthropological nature. There is the issue of planned parenthood (or rather the lack of it), domestic violence and the fact that many local people put their faith in traditional healers rather than in certified medical professionals when they fall ill.
In our capacity as medical and public health experts we were invited by African Parks to travel to the Republic of the Congo, to assist in shaping and improving the healthcare facilities and services in the area.
Centre Santé Intégré: the local medical clinic
The Centre Santé Intégré (CSI) is the local medical clinic in the main village of Mbomo. Since it is a state hospital, most staff members are employed and paid by the state. There is one physician active at the CSI who is employed by African Parks. There are no medical specialists in the Mbomo region or in surrounding districts. All types of morbidity are treated by the two CSI doctors and their medical team. This includes invasive surgical procedures, such as hernia operations and caesareans.
The difficulties surrounding the CSI were numerous. The following pictures give an impression of the contemporary state of the clinic, the level of hygiene and the adherence to safety regulations.
Inadequate disposal of used needles:
Well-trained medical staff is generally in short supply in rural areas in Africa, the district of Mbomo being no exception. Still, we met some very motivated and hard-working people employed at the CSI, and together with them we worked towards improving the level of care provision. We started with a thorough clean-up; we threw out all medication and medical supplies that were past expiry date, and we restructured and reorganised the medical stocks in a way that was ergonomic and efficient. We had witnessed on several occasions that during surgery, the medical assistants were unable to find the required medical supplies or instruments in the numerous unmarked cardboard boxes. Not being able to find the right medical equipment during an operation greatly jeopardises patient safety, so establishing an ergonomic and structured way of storing equipment was a relatively simple but effective step in improving care quality.
Medical waste was accumulating on a garbage pile right next to the hospital, including used needles, medicines and other potentially hazardous material. The PNOK-employed physician mentioned his desire to construct a De Monfort incinerator outside the hospital for medical waste disposal. A De Monfort Mark 8a Incinerator is a small-scale incinerator which was developed by De Monfort University of Leicester (UK), specifically for medical waste disposal in low-income settings. De Monfort University of Leicester was responsive to our request of providing a construction manual and a list of necessary supplies in French. Subsequently, we consulted a local stonemason and welder to verify if they would be able to construct the incinerator. They indicated they would be able to commence construction once special refractory bricks would be obtained. The PNOK indicated it would be willing to contribute financially to the construction costs of the incinerator. Our preparatory work laid the foundation for the actual construction of the De Monfort Mark 8a Incinerator, although our field mission came to an end before actual construction could commence.
During our stay we also organised a ‘try-out’ field mission with the mobile clinic. The mobile clinic is a terrain wagon loaded with basic medicines and medical supplies, with a small medical team which visits the villages in the periphery of Odzala-Kokoua National Park to provide basic medical care. However, the mobile clinic had been inactive for many months when we arrived. We decided to start with a try-out field mission to determine the healthcare needs in the region, to establish what medical supplies would be needed for mobile clinic trips and to determine how the mobile clinic should be organised and structured.
We spoke with an ASCOM (Assistant Santé Communautaire) from the village of Mbandza regarding the prevailing medical needs and the available facilities. While Mbandza does have a health centre, we were told there was a pressing shortage of medicines and medical tools. We decided Mbandza could serve as a decent experimental setting to assess what kinds of pathology were most prevalent, and what the focus of the mobile clinic should be. Our try-out field visit with the mobile clinic therefore took us to the village of Mbandza, where we set up shop for a day.
Observations and problems during mobile clinic field visit:
- The first thing that struck us was that the road to Mbandza was a bumpy one. The Republic of the Congo is a country with heavy seasonal rainfall. Upon our trip to Mbandza, we had been lucky enough to have several dry days in a row. With bad weather conditions, it is very plausible that the mobile clinic is not able to function as it will most likely get stuck in the mud. Simultaneously it is very hard for some of the people from the smaller villages to make their way to the CSI in Mbomo due to the poor conditions of the road and a lack of decent transportation.
- Due to a relatively long period of inactivity of the mobile clinic, combined with the fact that Mbandza’s own medical post had no supplies or active personnel members, there was a high care demand. After installing ourselves at the medical post, long lines of people seeking care presented themselves.
- We encountered that it was very difficult to keep the people at bay and have them respect the privacy of the patients we were treating. The treatment room was full with people waiting for a consultation. One reason people came inside was to seek shelter from the burning sun, and the fact they did not want to lose their place in line. Consequently though, we had great difficulties providing privacy for the patients.
- Due to the high care demand and the high number of patients presenting themselves, we had to compromise on standard medical procedures. Taking and testing the blood from everyone suspected to suffer from malaria proved to be too time consuming. Instead, we quickly screened for people meeting the typical symptoms of malaria and supplied them with a Coartem treatment, coupled with Paracetamol in case they experienced pain. Since many of the villagers did not speak French, a local interpreter explained the people how they should take the treatment.
- We gave everyone a standard de-worming treatment (albendazole or mebendazole).
- In a timespan of approximately 6 hours, we treated around 70 patients.
Our suggestions for the mobile clinic:
- We suggest that multivitamins and mebendazole/albendazole are distributed to all patients free of charge on future mobile clinic field visits.
- Privacy of patients is an issue, and procedures need to be developed as to ensure this privacy.
- We will actively seek benevolent donors for the mobile clinic. Still, if this results in the possibility of providing free healthcare with the mobile clinic, this introduces additional difficulties. Adherence to treatment is proven to be lower when treatment is free, and furthermore people’s expectations will increase. This requires additional critical reflection.
- The revenue model of the mobile clinic should be evaluated. As is, the PNOK (responsible for the mobile clinic) has a policy to charge every patient 2000 Congolese Francs (+- 3 euro), regardless of morbidity and medicines they are given. This is a heavily subsidised tariff, since the vast majority of patients receive medicines with a value of well over 2000 Francs. Then there are also national guidelines stating that pygmies are entitled to free healthcare, due to their underprivileged status and poverty. A substantial proportion of the villages the mobile clinic is expected to visit will have a pygmy population. Charging pygmies 2000 Francs might be at variance with national policies.
- We suggest that a dedicated nurse will run the mobile clinic and its administration. We have recently received news such a nurse has since been appointed; once the administrative formalities are finalised, the mobile clinic is expected to become fully operational again.
- We advise that the mobile clinic will have a fixed schedule and multiple field visits per week. It should be seen and treated as a structural healthcare delivery service in the region.
- The visits of the mobile clinic could be aligned with the regional vaccination programme.
- Based on the morbidity and care demands we encountered during our trip to Mbandza, we developed a provisional list of medical supplies and medicines for future mobile clinic trips
- Spread awareness of the importance of clean drinking water and promote the simple but effective Sodis method for water purification
As the user charges applied by the mobile clinic are far below break-even point, there are only 2 ways to safeguard the mobile clinic’s existence. Either user charges have to be significantly increased – which introduces moral dilemmas as the population is generally unable to afford high out-of-pocket expenses – or user charges have to be subsidized with donor funding. Benevolent investors with a philanthropic mind-set are therefore encouraged to contact us, as donor funding for expansion of the mobile clinic’s activities could carry the health status of the local population to a higher level through basic but essential medical care.