From the Africa Desk of Ambulance Today – Emergency Medicine Education in The DRC
By Michael Emmerich
The Africa Quarterly editorial discusses the challenges facing emergency medicine educators in The Democratic Republic of Congo (DRC). The DRC is the second largest country on the African continent with a population of almost 80 million. It is a major crossroad through Africa as it borders nine countries. The DRC continues to experience current political and social instability, as it has over its chequered past; and active fighting is still prevalent in certain regions today. The last two decades of conflict, mainly in the North-Eastern regions, has devastated the civilian population and led to the collapse of the healthcare infrastructure.
Government expenditure on health per capita remains one of the lowest in the world and Emergency Medicine has yet to be established as a specialty in the DRC. While most hospitals have emergency rooms or salle des urgences, this designation is more in name than an actual ER room; many have no standardised format, no recognised emergency medical equipment and they are rarely staffed by doctors or nurses with hardly any trained in emergency care. Lack of formal, structured training, lack of (emergency) equipment and fee- for-service for all patients entering the healthcare system are cited as barriers to care. Pre-hospital care is also not an established specialty, with no EMT colleges, ambulances being a rarity and no outside major centres. Where there are ambulances they are at best staffed by a nurse or just a driver with no medical training.
The 39 nationally-recognised medical schools, most of which are in urban
areas, are typically underfunded and all medical studies including residency are fully self-funded. There has been a recent proliferation of technical schools (more than 500) which offer varied levels of medical training. These institutes are not regulated, open without official approval and often operate as for-profit enterprises. Few students from any of the schools can spend the required years in clinical rotations due to a lack of participating hospitals. The overall result is an education of doubtful quality. There is currently no dedicated emergency care training integrated into medical or graduate schools.
A comprehensive study was undertaken1, jointly by the DRC Government and various international role players. Key findings of this 2012 report by USAID and Nursing Education Partnership Initiative (NEPI) noted the barriers to learning were as follows, including inadequate quality of health worker education:
• Lack of budget for maintenance and renovation of the existing infrastructures.
• Limited number of opening hours of libraries, skills labs and other infrastructures to students and teachers.
• Insufficient support of stakeholders including government and development partners regarding funding for construction.
• Insufficient budget for renovation of existing infrastructure.
• Lack of anatomic models in skills labs.
• Insufficient budget for purchasing basic materials and consumables that are necessary for clinical practice without necessarily relaying on what is found in clinical training sites.
• Inadequate system supply of books and other learning materials
• Lack of policy and budget for using the internet and computers in schools to encourage students and teachers to access information.
Although the report focuses on nurses and midwives, it must be stated that they serve at the frontline of most medical emergencies in the field and in hospitals and clinics. Therefore, the challenges they face in learning, will impact severely on their ability to work in an emergency medicine environment; added to the fact that emergency medicine is not part of their recognised curriculum.
I have been travelling and working in The DRC since 1999, across various provinces and regions, primarily teaching at a BLS, ILS and ALS level, (both pre- and in-hospital facilitating) and doing clinical governance and medical project management, so I can attest to the challenges. Short courses such as ACLS, PALS, ITLS, ATLS etc. which form the backbone of annual refresher training for many emergency medicine practitioners is relatively unknown, and only presented in a few regions of The DRC by training providers from other countries.
I am currently working in the Southern DRC teaching and practising emergency medicine with a team of Congolese doctors and nurses. What the statistics, data and educational shortcomings do not reveal is that the Congolese medical professionals I have interacted with have a real hunger for knowledge and a desire to learn about the challenging field of Emergency Medicine. In spite of all the challenges, the thirst for knowledge makes teaching and working in The DRC a genuine reward to the passionate committed EMS educator. Success is measured in baby steps and giant leaps – particularly when we move the classroom into the cramped under-equipped ER room or remote district ambulance.