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A medical technologist in central Africa; Peace Corps service in a hospital laboratory in Zaire included teaching medical technology in French and splitting dipsticks in half to stretch supplies.

A medical technologist in central Africa

Peace Corps service enticed us with a promise of adventure. More important, my husband and I wanted to use our skills--his as a chemist, mine as a medical technologist--to help people in a developing country. Then came the disappointing news: We learned that a medical technologist would be difficult to place.

Most developing countries lack the necessary support technology, the Peace Corps recruiter explained. He suggested I teach biology instead, but I knew that somewhere someone required a medical technologist. We decided to keep our applications on file, until they could locate that need.

A year later, the Peace Corps invitation finally arrived, offering posts in Zaire, formerly the Belgian Congo. My husband would teach chemistry and physics at a 650-student high school, and I would be a teaching technologist at a nearby hospital laboratory and medical technology school.

The invitation state that Zairians suffer greatly and needlessly from many preventable or easily treatable diseases, due partly to a simple lack of primary health care services. In some areas, half the children die before the age of five. The leading health problems are malnutrition, measles, malaria, gastrointestinal infections, parasites, polio, and tuberculosis.

The Peace Corps was helping by assigning qualified volunteers to the country's two medical technology schools. These volunteers were to provide classroom and inservice training until Zairian professionals could take over.

Our tour of duty began in July 1982 at the Peace Corps training center in Bukavu, eastern Zaire. There we received rigorous French and Zairian language training, and also engaged in practice teaching. Three months later, we set out for our assignments in Kimpese. Located along Zaire's only paved highway, this small town was 150 miles south of the capital city of Kinshasa.

My husband and I were put up in a cement block house on the grounds of the high school where he was to teach. Here are a few basic details about life away from work: While the electricity at home was fairly stable, the running water gave out after our first year there; we occasionally could get beef to eat, but we subsisted mainly on vegetables, particularly the cassava plant, whose coarse spinach-like leaves were first pounded and then cooked with spices and oil; and the temperature in our part of Zaire ranged from 70 to 95 F, while the humidity was often at 95 per cent.

At the Institut Medical Evangelique--an international, interdenominational mission hospital--we had relatively reliable cold running water and 24-hour electricity (both failed frequently). The surrounding community had neither utility. With transportation and connecting roadways also lacking, villages as close as five miles away were deprived of medical care.

Imagine making morning blood drawing rounds on your knees in dimly lit corridors. That describes phlebotomy at the 300-bed mission hospital. Many patients slept on the floor--they brought their own mats when admitted. As many as three babies shared a single incubator.

The hospital staff included Swedish, British, Canadian, American, and Zairian doctors and support personnel. Four expatriate technologists worked in the laboratory. Although teaching was our primary responsibility, we spent a lot of time at the bench alongside former students, getting the routine lab work out.

Several Zairian doctors had received some of their training in the U.S.; others were trained entirely in Zaire. We had to be very careful when questioning the local doctors' orders. If they became offended, they would leave the hospital and practice elsewhere.

The laboratory had no pathologist, and we certainly could have used one. I was always being asked for decisions I didn't feel qualified to make, like which desperately ill patient should receive our last unit of blood.

We could not obtain supplies locally. Everything had to be purchased from Europe or the United States. Orders were paid for in advance and commonly took a year to arrive. If a shipment came by boat, it might sit on the docks for weeks before someone did something about it. You sometimes had to bribe Zairian postal workers to bail out many packages, if they hadn't already opened them and sold the goods on the black market.

When supplies did make it through, they were often unusable due to outdating and spoilage. We favored dehydrated stains and reagents because of their lower shipping costs and increased stability.

The heat and humidity took a toll on instruments. For example, lenses would mold as a microscope sat on a counter.

Theft was a big problem. A Zairian technologist could easily double annual wages of $240 by selling such items as blood donation bags and urine pregnancy test cards to nearby clinics. The temptations were just too great, so we dreamed up an incredibly complicated system of numbering and accounting for all lab supplies.

Disposable plastic syringes, needles, and lancets were washed, sterilized, and reused until they could barely puncture the skin. At one point, I would have given anything for a Kim wipe or a gauze square to clean the pipets. The Red Cross finally came through with rolled bandages.

The hospital operated a four-year medical technology school and a nursing school. Students, ranging in age from 15 to 30, could take the entrance exam after completing their second year of high school. The 10 or so laboratory students accepted each year came from all over the country and lived in a dormitory at the hospital. They were intelligent, but we often saw large gaps in their scientific course work and language skills.

Although French was the official government language, the students generally spoke a Zairian dialect. Thus they sometimes understood a concept but could not express it. Teaching in French was also frustrating, since it was not my native language either.

There were no textbooks. All course material had to be written on the blackboard and meticulously copied into notebooks for future reference. First-year students spent most of their time in the classroom, with a brief laboratory orientation. The subject included basic biology and chemistry, anatomy and physiology, basic microscopy, and French.

In the second year, students picked up a few more laboratory hours along with an introduction to the major areas of study. Learning to draw blood took some of them a long time to master, both by fingerstick directly into pipets (for manual hematology) and by venipuncture. They seemed to lack the necessary manual dexterity; it didn't help that they were practicing with dull needles and glass syringes.

The third year program involved in-depth study of the areas introduced the year before, plus immunohematology. By now, students spent most of their time in the laboratory. The fourth year was devoted entirely to laboratory work, with rotations through the various departments.

The school year ran from September to July. Students then spent six weeks of the summer break observing and assisting in laboratories at rural clinics or at a 300-bed hospital in Kinshasa.

During my two years at the Institut, I taught blood banking and bacteriology and filled in at the bench. Here are thumbnail sketches of activity in all the departments:

* Blood bank. All donors were drawn in-house. We heared the usual excuses for not donating plus a few new ones. Some individuals were reluctant to part with any of their blood because it is a powerful, magical, mysterious substance. Typically, one man worried that donating blood to his nephew would give the child power over him.

Many of those willing to donate had malaria or were anemic. Owing to the shortage of healthy donors, we accepted quite a number who wouldn't have measured up to American standards. (Most of the expatriates donated every six weeks.) We also lacked the technology to do a lot of screening.

A verbal history was taken on every donor. A technologist then performed a hemoglobin from a fingerstick, grouped and typed the blood on a slide, and prepared a thick and thin smear for malaria examination. We accepted donors 12 gm/dl. Most "healthy" donors showed a few malarial trophozoites in the thick smear. Blood recipients were routinely treated for malaria upon transfusion. We did not ue units that demonstrated filaria or trypanosomes on the thick smear. In those cases, we treated the donor and used the unit to make blood agar.

The laboratory had no method for hepatitis testing, and we saved our VDRL reagents for diagnostic rather than screening purposes.

The lowest hemoglobin I ever saw was 1.9 gm/dl. That patient survived a case of hookworm. We often saw patients with a hemoglobin of just 4 gm/dl walk in for treatment. A transfusion of one unit of whole blood was the standard order for those with a hemoglobin of 6 gm/dl.

Sometimes we ran low on blood bags. The doctors would then decide to transfuse at a hemoglobin of 4 gm/dl instead of 6 gm/dl, but I still would be left with terrible triage decisions: Which patients would get the last of our blood supply? The question came down not to who needed the blood the most, but to who had the best chance of survival.

The laboratory had no antibody screening procedures--screen cells were not stable. Instead, we performed a three-phase crossmatch in saline and albumin. Coombs control check cells were prepared each day by incubating washed O-positive cells with diluted anti-D.

Antibodies were a problem. The most practical solution for an incompatible crossmatch was just to keep trying until we found a compatible unit. We did have a compatible unit. We did have a few typing sera, and we used them on all laboratory workers. It was then possible to make a presumptive identification of some antibodies by determining who in the lab reacted with the patient and who did not.

Blood groups B and AB appeared more frequently than in the U.S. Here's a rough breakdown of Zaire's genetic population: group O, 40 per cent; group A, 30 per cent; group B, 20 per cent; and group AB, 10 per cent. There was a large proportion of D.sup.u variants, and it also was not uncommon to find weak subgroups of A that would only agglutinate with anti-A,B.

* Chemistry. Equipped with a spectrophotometer, the chemistry department used much the same methods that I had learned as a student. Glucose and bilirubin were the most commonly ordered tests. When I arrived, the lab used the Folin-Wu method for glucose because copper sulfate was readily available. When a shipment of ortho-toluidine came in, wer switched to that manual method. It was much faster, simpler, and more accurate.

Other tests included BUN, creatinine, total protein, albumin, and less frequently, ALT and AST. When I left Zaire, they were trying to get an old flame photometer up and running for Na and K.

* Hematology. The hematology department processed about 40 specimens per day. Typical work included manual white counts and hemoglobins using Drabkin solution. Sedimentation rates were a popular means of diagnosing and monitoring tuberculosis.

Slides were used over and over. We would make a think smear on one end of the slide and place a thick drop on the other. A wax line kept the stains from migrating.

Plasmodium falciparum trophozoites were the most common organisms. We also identified Loa loa and an occasional trypanosome.

Sickle cell exams were performed by a sodium meta-bisulfate method and by electrophoresis; results from these two procedures often did not agree. Patients tested by electrophoresis were equally divided among S/S, A/S, and A/A.

* Urinalysis and parasitology. Like hematology, these were very busy areas. We had to cut urine dipsticks in half lengthwise to stretch the supply. But the dipsticks weren't stable in Zaire's heat and humidity, so urinalysis sometimes involved only a microscopic exam with a specific manual chemistry.

The parasitology staff examined about 60 specimens each day. Most stool specimens demostrated ova or parasites on the direct wet mount. Ascaris and Trichuris were the most common parasites. The town's water sources were heavily contaminated with schistosomes--both Schistosoma mansoni and Schistosoma hematobium.

* Bacteriology. The bacteriology department had two sections, routine and TB concentration. We processed about 20 specimens a day for TB concentration, and the positive rate was approximately 60 per cent. Procedures included NaOH liquification, centrifugal concentration, and a Ziehl Neelsen stain. We didn't do TB cultures for the same reason we didn't do many other things--lack of materials and personnel.

There was no safety hood, but I insisted on gloves, gowns, masks, limited entry to the room, and absolutely meticulous technique.

The routine bacteriology section made all its own media and processed about 15 cultures a day. Human blood from the blood bank was used for blood and chocolate agar, and human plasma was used for the coagulase test. To identify enterics, we employed a four-tube biochemical set consisting of indole, Kligler's iron agar, citrate, and urease. We had a few other sugars and amino acids to add if needed. Sometimes, organisms were not identifiable by these tests.

All organisms giving the appropriate biochemical reactions were tested with Salmonella typing sera. About 75 per cent of all blood cultures were positive for Salmonela typhi. Isolating Salmonella species from wounds surprised me at first, but I learned that the sickle cell children were especially susceptible.

At one point, we ran low on indole reagent. I stopped doing stool cultures to save the remaining reagent for blood cultures.

We did antibiotic susceptibilities by a Kirby-Bauer agar overlay technique to reduce contamination problems. Some Staphylococcus aureus populations showed the same susceptibility pattern I was used to seeing back home. S. aureus strains from isolated rural areas were highly susceptible, while those from cities, where it was possible to buy outdated antibiotics on street corners, were very resistant.

Our highest goal was to instill students and co-workers with a sense of professionalism. This proved to be difficult, challenging, and frustrating.

The medical technology school's failure rate was very high--only 40 per cent completed the four-year program. In most cases, dropouts failed the comprehensive exam at the end of each year of study. Those who did graduate generally headed for Kinshasa as soon as they fulfilled their one-year obligation to the hospital. Jobs in the capital city were scarce, but we could seldom convince graduates to stay on.

I'd like to say our efforts helped maked the hospital lab self-sufficient, but that didn't happen. Still, there were some victories. For example, one of our students, during his summer internship in Kinshasa, was amazed to see a lab worker report "normal flora" on a spinal fluid. This third-year student not only knew better but was appalled at the lack of expertise in a city hospital. When he related the incident to us, we realized our teaching had made an impact.

Upon returning to the States in July 1984, we settled in Las Vegas, where my husband had accepted a job in the Environmental Protection Agency's chemistry lab. We eventually readjusted, but we haven't forgotten Zaire. We keep in touch through Peach Corps organizations and newsletters, and we know that both the high school and the hospital are hanging in there. I send some of our outdated lab supplies to the Institut. To make sure the supplies get there, I ask missionaries who are vacationing in the U.S. to hand-carry them back.

Our two years in Zaire gave us an appreciation of the great difficulties faced by the people of developing nations. More than ever, we have an idea of the magnitude and complexity of the problems. The daily crises continue, and the wonderful colleagues we left behind--both Zairians and expatriates--continue to cope with them. They deserve as much helps as we can give them.
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Author:Graden, Mary K.
Publication:Medical Laboratory Observer
Date:Jun 1, 1986
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