A Month at Bongolo Hospital in Gabon

I recently finished a month in Gabon working at Bongolo hospital. We had spoken with several Bongolo missionary surgeons 3 years ago as we were deciding where to go for the Samaritans Purse post-residency program, and more recently Bongolo asked us to consider moving there to join their team. While we feel called to go back to Nyankunde, I felt like I should go and at least see Bongolo. At the very least, I would have the opportunity to see another mission hospital in action and learn from them. They also needed coverage, as one of their physicians was in the states for surgery, so it was a great opportunity to be of help. And who knew? Perhaps God would show me that He wanted us to move to Bongolo. I wanted to be open to that possibility.

Saying goodbye to the kids in Nairobi

In any event, I worked for a month at Bongolo. Unfortunately, due to passport issues, Anna and the kids were unable to join me, so this was the longest I have been away from them...too long (particularly since I spent 10 days at Mbingo in hospital following the month at Bongolo). Separation from family aside, it was a very good month. I learned a great deal from the doctors here. I was very impressed with the extent to which the doctors have trained the nurses (most of whom are not university educated) to act like nurse practitioners, consulting patients and treating based on protocols that the hospital has developed. I was inspired by PAACS, which is a Christian surgical residency training program that is found at a number of hospitals in Africa, including Bongolo. Currently, there are residents from Gabon, Angola, Congo (DRC), Burundi, and Madagascar, and two graduates of PAACS are now on the faculty here. I was impressed by their training and also by the community that they have formed and the Christian witness that they exude. And I was also blessed by the missionary community here, which warmly welcomed me, fed me, helped get me on my feet in the hospital, took me on hikes, introduced me to local food, took me canoeing and bridge-jumping, etc.

Bridge jumping

Canoeing with Barry Newman, one of the missionaries

Not least, I enjoyed being in such a beautiful place, located in Southern Gabon, in the jungle, right next to a whitewater rapid on a tropical river, and literally right above a large cave system. Pretty cool. In terms of fauna, I had the immense privilege of seeing a panther crossing the road while driving. This is almost unheard of, given the stealth of these creatures.

A very, VERY rare sighting of a panther

Most of the locals have never seen a panther, and none of the missionaries except for Barry who was in the car with me. What a gift to see this beautiful animal! Beyond this, I saw turacos, kingfishers (3 types), hornbills, ducks, ibises, pintailed whydas, pied wagtails, sunbirds, and a number of other birds. And on a hike through the jungle, we came across a python trail—a 10 inch wide smooth trail on the forest floor. At least, that’s what our guide told us!

Exploring the jungle

In terms of medicine (and pediatrics), I treated (or at least diagnosed) malaria, nephrotic syndrome, severe pneumonias with empyema, arrhythmias, strokes, cirrhosis, liver cancer, bladder cancer, lung cancer, seizures, HIV/AIDS, abcesses, anemia, dengue fever, gastroenteritis, diabetes, hypertension (with one woman presenting with a blood pressure of 290/140…a new record for me!), septic arthritis/osteomyelitis, sickle cell crises, LOTS of tuberculosis, complications of measles, neonatal sepsis, prematurity (the most premature child we received was a 900 gram baby), spina bifida, jaundice, hepatitis B, heart failure, emphysema…the list goes on. In the past I have had the reputation of being a white cloud (someone who doesn’t receive many admissions at the hospital when on call) and that continued at Bongolo. In 3 weeks of being on call, I got called into the hospital 4 times at night…a bit ridiculous for a busy hospital like Bongolo. This allowed me to take more call and give Izzy (my former UVA medical school classmate and now the head of the obstetrics service at Bongolo) and Deb (the veteran head of pediatrics at Bongolo) a bit more of a rest, so I’m grateful for that. I frequently did rounds with Deb, and it was fun to discuss patients together and learn from her decades-long experience in tropical pediatrics.

Deb Walker with one of her pediatric patients

Renee Valach (for whom I was covering), Izzy Elliot (my med school colleague), and myself

The contrast between Gabon and Congo (DRC)  in terms of medicine and public health was striking. On the one hand, Centre Medical Evangelique-Nyankunde (where we worked for 2 years and where we plan to return) is a former mission hospital (i.e. a hospital largely directed by missionaries and with extensive sources of outside funding) that is now Congolese-run and mostly funded by patients and by the Congolese government assisted (heavily) by the European Union). We love the fact that CME-Nyankunde is now run by the Congolese. However, we have also experienced firsthand the disadvantages: chronic funding shortages, frequent lack of financial transparency, decisions occasionally made on the basis of tribe or church denomination  rather than on who is most qualified for the job), frequent failure to plan for the future. None of these things are inherently Congolese or African, and to be clear, I think that the lack of financial transparency stems from a lack of organization rather than from funds being misappropriated or stolen. However, it is harder to find Congolese who are university-educated, who have graduate degrees, and who are trained and experienced in running large organizations. Congolese also generally haven’t worked in health systems like the ones that we Americans have trained in. We come from hospitals where deaths are relatively rare, where every death and every medical error is evaluated, where employees are fully paid, pharmacies are fully stocked, patients are generally insured, technology is practically unlimited, and mechanisms for quality improvement are highly developed. On the other hand, the norm in Congo is chronic financial insecurity leading to difficulty paying salaries, difficulty keeping medications stocked, limited technology and lab testing, limited reserve on an administrative level to evaluate quality of care and institute systems level improvements. Nurses are often demoralized and simply trying to survive in their lives outside the hospital. When you are not paid enough, you have to make up the slack growing your own crops. When you’re not paid enough, your kids get sent home because you haven’t paid the $7/month tuition. And then there is the matter of death. When almost every family has lost at least one child to malaria or some other illness, when you don’t have ventilators, 1:1 nursing to patient ratios, telemetry, advanced imaging, chemotherapy, etc, death comes a part of life, a daily hospital reality, rather than an unacceptable outcome, as it is in the States. This does not excuse laziness, medical malpractice, or substandard patient care, and it does not mean that the life of an African is less valuable than the life of an American, but it is true that medicine in Africa, medicine in low-resource settings, is just a bit different, particularly when not directed and funded by outside entities that are decidedly NOT low-resource.

            Bongolo, on the other hand, is a mission hospital. Administration is shared between Gabonese and missionaries. I don’t know where funding comes from, but I think there might be more outside funding, not to mention the fact that Gabonese generally have more financial resources than Congolese (at least those that we treat in Nyankunde).

Bongolo Hospital

Bongolo Hospital

Sunset at the mission

 I was very impressed by the collaboration between the Gabonese and the missionaries. Because the missionaries are part of the hospital administration, regular conversations take place about problems at the hospital. These conversations (which too often are lacking in Nyankunde) are fundamental to fixing problems, whether financial or otherwise. Patient outcomes are more systematically evaluated at Bongolo. Salaries are apparently always fully paid at Bongolo, which could not be more different from our reality in Nyankunde. There is also a national health insurance system in Gabon, which reduces the extent to which patient finances affect the quality (or amount) of care that they receive. There are also closer links with, and more visits by, medical specialists in the states. This is particularly true on the surgical side, with many American surgeons coming to help train the PAACS residents. But there is also a radiologist who has access to the Bongolo xray database and an established connection with a pathologist in the States. Not least, Bongolo is run by one denomination—l’Alliance Chretien (the Christian Alliance Mission) which is based in the States but now has many indigenous pastors in Gabon. On the other hand, CME-Nyankunde is overseen by 6 Congolese churches, which can make things a bit complicated. All this to say, while I love the fact that CME is Congolese run, I understand why many mission hospitals have chosen to stay mission hospitals rather than turning the reigns over completely to nationals, and I have appreciated and enjoyed the benefits of this decision at Bongolo.

Siko, the head of the lab at Bongolo and a Congolese

On the other hand, and ironically, the Gabonese health system seems to be a complete mess. There is a crisis of tuberculosis and particularly multi-drug-resistant (MDR) tuberculosis. Often normal TB medications are lacking at Gabonese hospitals and when they are not, Gabonese doctors (at least of late) are striking. Because of this, many TB patients are started on therapy and then the therapy is interrupted, contributing to resistance. And there is an extreme shortage of medications to treat resistant tuberculosis. Because of the lack of public health infrastructure, any patient started on TB therapy at Bongolo must stay at the hospital for 2 months for directly observed therapy. HIV treatment also seems to be a problem. Even vaccine coverage, which is a fundamental marker for the strength of a public health system, is subadequate. Case in point: One of the biggest measles epidemics in the world is occurring in Gabon.

Bongolo Falls

In contrast, for all Congo’s problems, its public health system seems fairly strong. There is a huge network of health centers which supervise most of the TB treatment and, in tandem with large vaccination campaigns, carry out most of the childhood vaccines. Contrary to Bongolo, where I had to fill out all the paperwork and records for every tuberculosis patient and where these patients had to stay at the hospital for 2 months, in Nyankunde I go and talk to the health center nurse, explain that I think the patient has TB, give the bed number and the weight, and the health center starts the medicines, fills out the paperwork and supervises the treatment. As soon as the patient is stable for discharge (usually after about 2 weeks), the patient can go home and supervision of their tuberculosis treatment is carried out by their local health center. It is nice to be able to applaud Congo’s government for something!