Before any patients are seen, one of the nurses gives a PowerPoint presentation on a relevant health topic. Recent themes include oral health, diabetes, and smoking. Deliberately targeting populations in which health education is often lacking, these informal presentations capitalize on a captive audience and distill important health messages into 20-minute crash courses.
I’d asked Nur, one of the clinic’s doctors, if I could shadow him for a morning to get a feel for the patient flow and types of cases he sees, as well as observe George in action. Before coming to Borneo, I would’ve been hard-pressed to identify an occasion in which George and I might cross paths, professionally. The informal nature of work here presented an ideal opportunity.
While we wait in one of the exam rooms for the conclusion of the morning’s presentation, I take in the scene: a buzzing wasp lands on the otoscope. Nur shoos out the rascal clinic cat, Ikan, since in the past few days the little runt has been particularly malodorous. Above a desk, hand-drawn posters illustrate the importance of both hand washing and eating fresh fruits and vegetables. Along one wall is a bed with a sagging cushion and well-worn sheet. The open windows look out on a rather lovely view of a lush flowering plant (perhaps the source of those wasps)!
We begin a rapid-fire procession through patients ranging in age from preteens to octogenarians. I’m immediately impressed by Nur’s thoroughness and clear passion for the wellbeing of his patients. He’s efficient, yet never condescending or perturbed by their questions or shyness.
After talking with a patient, Nur translates for George’s and my benefit. George and Nur discuss potential diagnoses and treatment options, sometimes completing a physical exam or sending a patient to the back for blood work.
I’m enchanted by a teenage girl’s bejeweled hijab as Nur listens to her chest. She’s had a persistent cough for a month. In tropical areas, Nur says, coughs of over three weeks in duration raise a red flag for TB. In addition to testing her sputum, Nur decides to start her on a round of antibiotics. If the cough abates, then the course of treatment will have functioned as a sort of diagnostic test.
George explains that antibiotics are used more liberally here than they would be at home. Given the lack of diagnostic tools and the difficulty of establishing continuous care for patients who live far from the clinic, antibiotics are used empirically – that is, in the absence of a firm medical diagnosis – more frequently than most physicians in the US would find acceptable.
Despite the lack of technology and resources, Nur and the other doctors here are effective and skilled in treating patients. George adds that Nur is especially adept at asking the right ‘review of systems’ questions. Instead of sending a patient with gastric pain for a battery of blood tests and a colonoscopy/endoscopy, Nur asks a series of questions in increasing detail to suss out any red flags and better inform what will be an empirical course of treatment.
One woman, six months along, was in a motorbike accident (all too common here) and is now experiencing cramping. When she pulls up her shirt for the ultrasound, we see a grey, ashy substance spread around her protruding belly button. Nur explains that she, like many patients who end up at the clinic, sought treatment from her village’s healer before coming in. The poultice was applied for its purported healing benefits. After the ultrasound, Nur reassures her that the baby is fine.
Towards the end of the morning, Ronald, another physician, stops by to consult on a patient. He’s swatting at himself, and laments that the other exam room is “so full of ants right now!” Only in Borneo…