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The cost of stroke in Zambia – Part II

MAKING THE ROUNDS
COMPLETED in 1975, University Teaching Hospital is a bewildering complex of buildings linked by open-air walkways two and three stories in the air. Bright blue jacaranda trees brighten the courtyards, and everywhere cleaners with mops attack the grime of the city.
On a Monday morning in September, Saylor leads the neurology trainees on morning rounds through UTH’s patient wards. For visitors accustomed to the semi-private rooms in US hospitals, the wards are jarring. Patients are packed in, dozens at a time, in some cases in beds arranged head-to-toe.
There is none of the monitoring technology found in western hospitals, and few receive IV drips. There are no televisions.
One patient, a 72-year-old farmer from southern Zambia, had seizures and lost his ability to speak clearly. Chishimba conducts a physical examination, lifting his legs and arms, and examining his pupils with the flashlight of a mobile phone. She and Saylor confer with the patient’s grandson, McDonald, who is spending the day at his bedside.
Most direct patient care at UTH is provided not by nurses or orderlies, but family members. It’s they who feed and bathe the patients, and find them their mismatched sheets and blankets. Called bedsiders, they’re often the wives and mothers of patients, and they are the hospital’s workaround for a lack of resources. Bedsiders may travel great distances, and unable to afford hotels in Lusaka, they sleep in the hospital’s courtyard. In the mornings, they can be found slumbering, cooking, or socializing, while their laundry hangs to dry on shrubbery.
UTH doctors universally praise the bedsiders, who, like McDonald, are available to answer questions about the patient. His grandfather, who grows maize and sweet potatoes, first had stroke-like symptoms two weeks ago, and was sent from his regional hospital to UTH. The doctors are still waiting for a CT scan; the test was delayed because the family couldn’t afford the 900 kwacha ($66) fee, McDonald says, and had to wait several days for a subsidy to be granted by social workers.
Saylor asks McDonald if his grandfather is slurring his words, a condition called dysarthria, which would suggest a small stroke deep in the brain, or if he’s making up new words, a condition called aphasia and caused by a stroke in a large blood vessel. The difference could guide his course of treatment.
In a country where stroke is so prevalent, determining what isn’t stoke can be a huge challenge, Saylor says. One benefit of having Zambian neurologists will be their ability to diagnose other diseases of the brain and nervous system. “When I arrived, everyone admitted with weakness on one side of their body was admitted as a stroke,” she says. “But maybe it’s MS. Maybe it’s a brain tumor.”
Or maybe it’s something even less common. At a walk-in clinic for neurology patients held at UTH every Wednesday morning, the doctors see the full scope of neurological problems in Zambia. Until the clinic opened, Zambian doctors had never diagnosed patients with multiple sclerosis or neuromyelitis optica, Zimba says. Now, doctors across Zambia send patients with undiagnosed disorders to the clinic.
“When I was training as a physician, the teaching was that these are Western diseases,” Zimba says. “But then when we started the service, some of the diseases we thought were not there, I mean, we’ve been seeing them.”
THE COST OF STROKE
Still, many of the weekly clinic’s attendees are stroke patients who return every few months for checkups and to have prescriptions renewed. The lucky ones are examined in private; others are crowded into one room, as three neurologists conduct interviews separated by curtains. Outside the open windows, a whining generator adds to the din.
Zacheus Chikasa, 44, waited with his wife and grandson. After suffering a stroke in July of 2015, he was left unable to walk without a cane. A middle class swimming pool salesman with three children, Chikasa was forced to retire and his two younger children had to drop out of school. Chikasa blamed himself when his oldest daughter became pregnant by a man who later left her. Had he been better able to provide for her, he says, she would have stayed home.
“It’s a difficult life,” he says. “Everything has changed for us.”
When Chikasa first suffered his stroke, he had an intense headache and blurred vision, but was able to walk. It was only after he was treated in the hospital that his stroke grew worse, he says.
Though it’s impossible to know now, Chikasa may have been the victim of a common conundrum in emergency stroke care in poor countries, when it can be impossible to determine the type of stroke.
While ischemic strokes are often caused by high blood pressure, once they have occurred, that same high pressure can also force blood through a delicate network of collateral blood vessels, supplying the affected area of the brain with oxygen and glucose even when a larger vessel is blocked. When emergency stroke patients are given medication to reduce their high blood pressure, blood may no longer flow through those collateral vessels, increasing the damage to the brain.
Hemorrhagic stroke patients with uncontrolled brain bleeding, on the other hand, benefit when their blood pressure is immediately reduced. It’s not clear how Chikasa’s stroke was diagnosed, but his initial treatment may have lowered his blood pressure too quickly.
Improved neurological care will likely improve outcomes for patients like Chikasa. Even more critical is improving public knowledge of lifestyle risks that can lead to high blood pressure.
Zambia’s gap in public awareness of stroke risk is one of the reasons Mashina Chomba, another trainee, began a career in medicine. He was in high school when his father had his first stroke in 2001. Diabetic and with high blood pressure, he recovered, only to have subsequent strokes.
High blood pressure, or hypertension, puts stress on blood vessels. The pressure can either lead the vessels to burst, causing a hemorrhagic stroke, or to crack, which creates clotting that can lead to ischemic strokes. “No one ever took the time to explain to my father about his diet,” Chomba says. “No one told him what traditional African foods to avoid.”
Hypertension can be hereditary, but it’s also a product of obesity, smoking, and—especially in Zambia—high salt intake. Zambians add salt liberally to most meals: Even UTH’s makeshift cafeteria hands out packets of salt freely. Among adults in Zambia’s urban areas, 35 percent have high blood pressure, according to a 2011 study, among the highest known rates in sub-Saharan Africa.
A public awareness campaign is still in its infancy, as are efforts to increase monitoring and medication. Meanwhile, blood pressure drugs aren’t available in many rural areas, says Fastone Goma, founding president of the Zambia Heart and Stroke Association, and government-run pharmacies are the worst supplied. “The government doesn’t really appreciate the gravity of the situation,” he says.
So while prevention may ultimately prove the most effective strategy, in the near term, Zambia’s strokes will need to be treated.
THE PROMISE OF BETTER CARE
The neurologists in the training program were joined by another class that began in October, and yet another will begin next year. In six years, Saylor says, the program will have trained nine Zambian neurologists.
The hope is that these new doctors will introduce practices and procedures that improve stroke diagnosis and treatment and, eventually, pave the way for emergency stroke care. “That is my expectation—to do tPA and all sorts of surgical interventions,” says Zimba. “Of course I understand the setting where we are. We are really limited by resources.”
But Zimba points to Zambia’s history with nephrology: As recently as 2004, the nation didn’t have the ability to perform dialysis for diabetes patients with failing kidneys, and patients who could afford it were sent to India. Now, there are 24 dialysis machines at UTH and others at regional hospitals.
Initially, emergency stroke care would probably be available only to the wealthy and to VIPs, Zimba says. But eventually it could be made available to a wider group who can get to the hospital within the narrow window for treatment.
Birbeck points out that even if most patients won’t be treated with tPA or surgery, their potential availability will speed up the metabolism of stroke care for everyone. With the potential for emergency intervention, stroke could shift from a disease that’s chronic to one that’s acute. Even the patients who arrive too late for tPA would still benefit from being treated in an emergency setting.
“If you thought of stroke as an emergency, it would change everything,” Zimba says.
Even without reaching that standard of care, there is much that can be done for Zambian stroke patients. Saylor is leading a study to determine if any of the non-technological scoring systems devised by doctors in Japan, the UK, and Thailand would work in Zambia to diagnose stroke types without a scan.
But perhaps the single most effective improvement for stroke patients—and the one Zimba is most focused on—would be the creation of dedicated stroke units in Zambian hospitals.
Stroke patients are now scattered across the wards, surrounded by patients with other ailments. A stroke unit could gather them together, cared for by nurses trained in stroke care.
Simple interventions to decrease stroke mortality would be the norm: Patients could be elevated in bed, reducing the risk of inhaling food or water. There are no reclining beds at UTH, but a ready supply of foam wedges would do the trick—better, at least, than shoving a box under a mattress to be unwittingly removed by a nurse or orderly.
Bedsiders could also be educated in how to care for their loved ones with stroke, Zimba says. Sometimes, stroke patients aspirate when family members try to give patients food or water—a problem made worse by UTH’s requirement that they must pay for nasal feeding tubes, leading bedsiders to feed them by hand.
A similar unit at Ignance Deen Hospital in Conakry, Guinea, led to significantly improved outcomes for stroke patients. Fatalities from stroke fell from 22.3 percent to 7.2 percent, and complications like pneumonia fell by similar rates. Through trial and error, Zambia’s doctors could eventually introduce stroke units throughout the country.
All of these plans, of course, rely on Zambian neurologists invested in the care of their fellow citizens, who have credibility with the administrators of the hospital and at the ministry of health, and who are well versed in both the science and art of stroke care.
Training Zambian neurologists won’t solve the country’s stroke epidemic. But it’s impossible to see the beginning of a solution without more Zambian neurologists.
This story was supported by the Pulitzer Center on Crisis Reporting.






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