What is a Hospital?

"Hospital." The word brings to mind many immediate images, but these images have changed for me since I began a career in medicine. It used to be: important people with clipboards, machines that went beep, fear and hope, waiting for an answer. Then it became: waiting for pages, orders not being followed, making decisions about medicines, and pressures to discharge.

I'm sure all of you have thoughts/feelings/fears when you stop and think about "hospital." Perhaps you imagine cleanliness, medicine, waiting for nurses, filling out menus for tasteless over-boiled hospital food, sponge baths, wheelchairs, tests, and diagnoses. For others it may be the "hospital smell" or the sound of hard shoes walking down long corridors. Maybe it's the waiting room: pacing, waiting, praying.

I want you to try and put the images aside for a moment. I want to tell you about a hospital here, in the town of Gulu, the only large town in the Gulu District of northern Uganda. You must really clear your mind, for what I am about to describe bears little resemblance to your impression of "hospital." Maybe we should even choose another word. Maybe chair, or spoon. In any case, I digress. Just try to clear your mind and imagine …

The first thing I notice is the people. People everywhere. Sitting on the ground, washing clothes, cooking … can that be right? Are they really cooking? Why are there so many people around? They don't look that sick. They can't be patients. Just who are they?

They are the caretakers. No one can go to hospital without a caretaker. You would likely die if you went to the hospital without a caretaker. You need someone to cook for you, to care for you, to wash you, and to wash your clothes. So when we transport a patient from our clinic at the displaced person camp in Awere, Gulu District, we transfer the patient, their caretaker, utensils, charcoal, food, and clothing.

Then I notice the absence of so much. There is no electricity. Where are the staff? There are no machines at all. I mean no IV machines to monitor fluids, no x-ray machines, no ultrasounds, no automatic drug carts.

It is Wednesday. We had planned on staying over in Awere, but there is a very sick boy in respiratory distress. Likely he has pneumonia. He needs IV antibiotics and he needs oxygen. There is no oxygen in Awere. So instead of spending the night, we pack up after one hour and start the two-and-a-half-hour drive back to Gulu. I am worried as I watch him struggle to breathe. I have seen worse respiratory distress, but I know that children can crash really quickly. He will eventually tire and he needs oxygen.

We arrive at Gulu government hospital. It is the one hospital in town where patients are treated for free. We pull the Land Cruiser up to the pediatric ward. It is basically a dark shed with cots and cribs. It is filthy. There are children in the beds that are also filthy. This is not unusual. I am not shocked. But when I search for a nurse or a nursing aid, I find no one. A patient directs me to another ward.

I go with Delphine, the nurse I work with from Médecins sans Frontières (MSF), to find the nurse. We go to ward after ward. Medicine, Surgery, Therapeutic Feeding Centre. There are no staff! Really none. Finally, we find a woman who speaks English. She isn't wearing nursing clothing. Perhaps she is a clerk of some sort. She tells us that there is a meeting with some public official going on. She guides us to the general area and we take off, jogging across the grounds. I see many staff members filing into a meeting. I excuse myself in the local language and a nurse stops to speak to me. I tell her of my worry and I am sure she senses the panic in my voice. She promises me that she will send someone to pediatrics to tend to the boy. I sigh and walk back to the building to wait.

Minutes pass. They keep on passing. He keeps on struggling to breathe. It has now been an hour since we arrived. I am desperate. I, again, go from ward to ward. I am not hoping to find a doctor. We never find doctors when we come after 5pm. I accept the fact that none of my transfers will see a doctor until at least the next day. But surely a nurse should be there. Surely a nurse can provide oxygen. I finally find the same clerk I spoke to earlier. I tell her how worried I am. It is getting very late. We need to leave. She promises me that she will ensure that someone sees the boy in the next hour. I hope that she is serious. I do not know what else to do.

So we leave and I pray that I am not leaving him to die. It is a long night for me. I wonder how the night is for him.

I am scared to go back to the hospital. When we arrive the next day, the nurse takes us over to a corpse and says she is sorry. I can barely stand up, but then I realize that this corpse is too small to be the boy. It is one of the twins we had transferred a couple of days before. I feel … relieved? Or … something … for the second before I feel the grief of the mother standing next to her dead infant while the other one continues to feed from her breast.

I find the boy, and he is alive. He looks a bit better. I do not know if he received oxygen. I can never find a chart or someone who really knows what has happened to a patient. Sometimes we can't find a patient we have referred and the nurses just say that s/he died. Sometimes this is true. Other times, the patient just moved to another ward, but no one knows. Once a patient just left the hospital. I have had patients wait in a hospital bed for four days with no treatment because the doctor is away. There are no replacements when someone is away. The nurses can't take orders from me – I don't work there. So the patients just sit.

When I am really worried, I go and speak to the medical superintendent and he ensures the patient gets treatment. If I am really, really worried, I try to transfer the patient to another hospital that we need to pay for, and I hope that the medical director of my program agrees to cover the expense. The other hospital is much better. There are still caregivers. It is still hard to find a chart. But usually the patients there see a doctor.

So my image of hospital has changed drastically. I am getting used to the dirt. I find it normal for there to be a cooking area for the caregivers. I am used to the dark wards. But I don't think I will ever get used to the absence of doctors. What is a hospital without doctors?

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For another story by Dr. Bernard, see I Got to Decide.

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