Mervyn Dean reflects on culture specific medicine


In the past 10 days or so I’ve settled into some sort of routine at KCMC, seeing patients on the wards in the morning, and in the afternoons either following up on administrative matters or trying to arrange teaching sessions, the latter with some small degree of success.

As I am sure anyone who has worked in Africa will confirm, one sees both familiar and unfamiliar conditions here. I have seen several patients with Kaposi’s sarcoma as a result of HIV/AIDS, including one very sick 12 year old girl who sadly was not well enough for chemotherapy and died a few days after I had first seen her. Several of the HIV/AIDS patients I have seen, paediatric and adult, have become sick because of not understanding that they have to take their ARV medication continuously, not like a short course of antibiotics. Where the fault lies – with the patient for not following instructions, the healthcare worker for not explaining, or perhaps yet another reason – I do not know, but it is so sad to see patients presenting with advanced preventable disease.

Unfortunately it seems to be the norm for patients to present late. On the gynaecology service I have seen a number of patients who at their first presentation of uterine cervical cancer have stage IV disease, and patients with other cancers similarly present late. The reasons are various: lack of medical facilities where the patient lives, not being able to afford to see the physician or travel to the referral centre, or social reasons such as not being able (or wanting) to leave the family.

What surprises me is the grateful way that the patients accept the news of their advanced disease. A few times the patient I have seen has not been told, or has not understood, their condition and has asked me to tell them. I warn them that I haven’t got good news for them, but they have all insisted that they want to know. In fact, I think they already have a good idea of the seriousness of their disease. Having been told that they have advanced cancer that there is no cure but there may be treatment to “slow the disease,” or even that there is no treatment for them, they have all been extremely grateful, smiling and shaking my hand.

Of course, working here has many other surprises, some greater than others. One in particular that bothers me is the lack of privacy and confidentiality. I previously mentioned the crowding of some of the wards. Where I used to work we could draw a screen around the patient’s bed knowing it was at least sight proof and pretending it was soundproof in order to give us some impression of confidentiality. Here some rooms have only one set of mobile screens, and others not even that. When I tell a patient I want to examine him or her they immediately undo and fully open their clothing with no regard for the fact that everyone else in the room, and sometimes, if I’m not quick enough to close the door, anyone in the corridor, can see them. I try to at least keep the door closed, but it is such a busy place that people are coming in and out of the room continuously. Neither the patient nor the staff seem concerned by this lack of privacy, but it certainly bothers me.

I do try to get screens and/or keep the door closed, but at the same time wonder if I’m imposing my culture’s values onto this culture. Is privacy as I have described a basic human right, or is it culture specific? In Canada we have professional ethics, social morals and privacy legislation that dictates our practices in this area, and certainly our patients would object strongly if we didn’t observe these practices. Do the patients here not expect privacy because it is not within their culture to do so, or is it something that has been imposed upon them and that they now accept as the norm? I really don’t know. For now I will continue to try to maintain privacy because I am uncomfortable not doing so, but I will wonder if I’m doing the right thing.

Mervyn Dean is a palliative care physician recently retired from his post in Corner Brook, NL, Canada. He has come on a voluntary basis to the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, northeastern Tanzania, to help provide and teach palliative care.