The essence of simplicity
As a junior surgical resident I am working for half a year in St Francis Hospital in Zambia.
This is a small story about the search for strapping, Malcolm Gladwell and a crocodile.
At sunset a combination of African clichés appear at the horizon as if they were rehearsed. Women in colourful chitenges carry big buckets of water on their heads, an old Toyota leaves a big cloud of dust in which schoolchildren and their uniforms disappear. With my old Nokia (3210) in my hand I greet the guard as I walk into the St Francis Hospital. “Muli bwanji?” (How are you?) It’s one of the few sentences I know in Chichewa. He greets me back and laughs politely, probably because of my bad pronunciation.
Only half an hour later the surgeon on call and I are pushing a trolley towards the operating theatre. The moon gives light to our footsteps en the night crickets and other mysterious African insects fill the silence of the darkness. My shirt sticking to my back remembers me of the heat of the day. On the trolley lies a little boy, only six years old. His left leg is wrapped in bandages and some old cardboard glove boxes. He was playing with some friends at the riverside this afternoon. A hungry crocodile ruined their fun and went for his leg. So far he was lucky. I think about the crocodiles in my country: trampolines and playgrounds.
The operating theatres are a conglomerate of medical equipment donated by several parties: coats from the Netherlands, instruments from the UK, gauzes from China. Nevertheless, the light switch and the water tap remain the two elements that are most unpredictable. Several times a day de tap remains empty and the tl-tube dark. “You should not make surgery more difficult than it actually is.”, my supervisor says while scrubbing up. Interestingly, he has always been working in a high-end academic hospital in the Netherlands. But he appears to be right. Because even with a head torch and a table full of semi-suitable instruments he is able to do what is needed: debridement, suturing and fixation of the fracture.
You could argue that Zambia typically can be categorised as an ‘underdog’ country. Sixty percent of the population lives below the poverty line and the majority does not have access to running water nor electricity. It is a country with a lot of potential but few possibilities. Malcolm Gladwell, author of the book “David and Goliath” defines kids in poor suburbs, dyslectic people and women in technical universities also as typical underdogs. But in contrast with our general expectations regarding these groups, he shows that an inferior position can actually be beneficial. Underdogs tend to develop so called compensatory capacities that others would not expect. In that way Zambia could actually be in a favourable position, whereas its limits to simplicity result in the awareness of importance of the essence.
After working one year as a medical resident in the surgery department of a hospital in the Netherlands, I felt like a very small wheel in an enormous machine of health care. Twenty percent of my day consisted of medical work; eighty percent was administration and communication. The machine was like a spider web linking local care, physiotherapists, nutritionists, medical specialists, family care takers, hygienists, students, managers and many more. All of this tightly regulated by protocol’s, carefully written and cautiously controlled by government organs. It is a smooth operating machine with very high standard care. Nevertheless, it has also resulted in a society with a never-ending demand of a zero risk, pain free and carefree life that results in committees and congresses that supply solutions for problems that maybe weren’t a problem in the first place.
Gladwell refers in his book to the so-called ‘inverted U-shape’. Several researchers amongst who Daniel Kahneman and Barry Schwartz have shown that for example the tendency to improve the quality of education by reducing class sizes is only beneficial to a certain extent. A class containing fewer than eighteen pupils is no longer a class for it is no longer possible to be anonymous and children have to few peers who ask question they don’t dare to ask themselves. It would be comparing apples with pears to say that we should go back to a hospital lacking water or electricity in the western world, nevertheless an abundance of resources in health care could lead to disease in stead of health. The balance remains difficult. Absolute scarcity is undeniably problematic, as is total abundance. The optimum is yet to be found.
A second interesting argument in Gladwell’s book is the fact that underdogs are often surrounded by less comfortable circumstances. But actually, due to this unfavourable environment, they are more alert and creative. Look at the following question: A tennis racket and a ball together cost 1.10€. The racket costs 1€ more than the ball. How much does the ball cost? This is a question from the Cognitive Reflection Test, the world’s shortest intelligence question, containing three questions. On average, students of a top league university in the USA, score two out of three questions correct. Remarkably though, when researchers Alter and Oppenheimer printed the question in a very hard to read light grey colour and 7. Font, the students scored almost a point higher. This phenomenon is described as ‘desirable obstacles’. So maybe the lack of laboratory investigations and CT-scanners could lead to better clinical judgement of doctors? Relative scarcity seems to stimulate creativity, which could lead to lower costs in care.
However, without investment in knowledge, creativity is worthless. To work in an African hospital is a dual challenge. On one hand the pathology is often exceptional en beyond the criteria of any protocol, on the other the resources to diagnose are very limited. This demands a great ability to improvise which can be risky because the only way creativity will be rewarding is when the mind that is improvising can rely on a great amount of knowledge and experience. The naïve creative thoughts of a clinician who does not know the standard are oblivious.
I am looking for the last bit of strapping to secure a cannula. In contrast with the abundant storerooms in the western world, it is easy to look for something in an almost empty closet. The coming years, hospitals in the West will bulge from the amount of gadgets, trials and new treatments being developed. The challenge for the future doctor will not be to investigate, but knowing what not to investigate. To teach ourselves and our patients to be at ease with a certain amount of insecurity. It seems something that is easier to learn in Africa.
The amount of stars has become uncountable. Tired but satisfied I walk out of the hospital. The guard wishes me a good night. “A mairo.”, he says. I smile because of the suitability of the world at this point. Mairo can mean tomorrow and yesterday; it is a matter of perspective. The torch of my old Nokia phone shines in the darkness to find the keyhole of my door. I charged the battery a week ago. Doubtful I climb in my bed, under my mosquito net, no longer sure who is David and who is Goliath, the old Nokia or the Iphone, who is actually the underdog here, Zambia or the Netherlands?