Healthcare in Togo

Piercing shrieks came without pause from the small, wiry little guy rocking on the hard, white tile table. This was the rhythm and frequency of sheer, agonizing and raw pain, and I had never heard nor seen pain like this before. The shaking, rocking, screaming mass was an innocent, young boy who was getting stitched up without anesthesia.

The boy, Matthieu, had fallen off his bike the night before and scraped his knee. Fearful of getting in trouble, he did not tell his father about the ping-pong ball sized gash. When his father discovered the deep wound the next morning, he immediately brought Matthieu to the clinic for care, but the hours that had passed were unforgiving. The skin around the wound had already relaxed and curled back, which made for stitches that would need to be forced and pulled in directions that almost didn’t seem natural.

The clinic could not offer Matthieu relief through anesthetic or pain medication because the clinic just did not have any. The clinic I work in has a constant shortage of vital medications and supplies, which is a grave barrier to access to proper healthcare. My perspective on what access to health care means and the different forms that barriers to care can take has deepened since working in the clinic.

The Togolese health system and health facilities are widely stratified, which contributes to this lack of medical supplies in local clinics. There are specialized hospitals in the capital city of Lome that are the only access point for special procedures and treatments. Each of the five regional capitals has hospitals that can perform basic operations like caesarean sections and appendectomies. Moving outside of the capital cities to the larger village towns, the facilities shift from a hospital setting to a clinic. The larger village towns have large clinics that doctors lead and manage. These clinics can run lab tests but do not perform surgeries. These large clinics manage a whole health district full of other smaller clinics, and they are the access points for the smaller clinics to re-stock medications and vaccinations. Larger villages that are not towns have smaller clinics that a physician assistant or highly certified nurse will manage. These clinics employ midwives and can also perform lab tests. The next health facility, which is found in the smaller villages like the one I am living in is just a basic clinic. The clinic is run by a nurse and there is no midwife, just a birth attendant. The clinic I work out of can perform basic medical services, has a small pharmacy, and serves 13 villages. The 12 villages outside of the clinic are more than five kilometers (about three miles) away and do not have a health facility within the village itself. Instead, these villages are served by one or two community health workers. Community health workers make up the bottom of the health system and they are the only access points to health care in villages where no clinic exists. They can give out basic antibiotics, medications and malaria treatments.

The health system is vast and situated in a linguistically complex landscape where more than 40 languages are spoken. Only those with some level of education speak French, while each ethnicity has its own language, so language is a barrier to healthcare in Togo. Nurses and midwives in clinics speak French well, but they run into difficulties treating patients when they don’t speak or understand the same local language as the patient. The birth attendant at my clinic only speaks one local language, Ewe, and French. Seven different languages are spoken in the village where I live, so when an uneducated and pregnant woman comes into the clinic who doesn’t understand Ewe or didn’t bring her husband (since most husbands will understand French) she has a very hard time communicating with the birth attendant. On several occasions the birth attendant has asked other patients who are waiting to see the nurse to be her translator.

The most striking barrier to healthcare I have observed is the lack of patient respect and therefore lack of patient empowerment. Respect for patients and a compassionate bedside manner are not in the curriculum of Togo’s medical and nursing schools. Patients’ rights are non-existent. The culture itself if hierarchical--meaning it has an informal caste system--and males of any rank in society are considered “more important” than females, which contributes to health personnel’s lack of respect for patients. I have watched the assistant nurse yell at patients or turn them away. The pharmacist, who is also the village bill collector, has a tendency to take small amounts of money out of the safe for his own use. I stood in utter disbelief as I witnessed my fourth childbirth and saw the birth attendant pull out a wooden stick with rusty nail on one end and hit the laboring woman. Often medical authorities do not share their diagnosis with patients, so the patients do not understand why they need to buy certain medications. Because of their disrespectful treatment, they aren’t empowered to ask the important questions.

In context, however, the large lack of access to care is unsurprising. The clinic employs four health personnel who are expected to serve 13 villages which, so more than 10,000 patients. The clinic is understaffed and the staff is underpaid. It sounds terrible to justify the disrespect for patients, but we need to realize that these concepts are not taught in school and they aren’t part of the culture. The culture is hierarchical and biased towards males. As Americans, we are taught starting in Kindergarten to use our power to treat individuals the way we ourselves want to be treated. Respect is a learned concept that takes years of practice and will enter Togo’s healthcare system once it is taught in the medical schools, like bedside manner is taught in American medical schools.