Italian training program in Cameroon: A model for developing cultural competence

Due to its geographic position in southern Europe, with miles of coastline on virtually all sides of the peninsula, Italy has often represented a “first approach” for people emigrating from North Africa and the Middle East to Europe and North America. Italy’s role as an international gateway means health care professionals in the country must be trained in cultural awareness to meet the needs of individuals representing a spectrum of backgrounds and ethnicities. To this end, the department of surgery at Pietro Valdoni, Sapienza University of Rome, Italy, has long supported a small rural hospital in the pluvial forest of South Cameroon located in Central Africa. Saint-Luc, a not-for-profit hospital, is part of the Mission Catholique de Bimengue, and our surgical residents do voluntary rotations at this facility.

Surgical rotations in Central Africa

The training program, started in 1988 with leadership from then-chief of surgery and a co-author of this article, Prof. Sergio Stipa, MD, FACS, provides residents with a six-month experience in an African mission hospital. Soon after the first residents began their rotations, they indicated that they found it to be a positive experience. In fact, residents have played a significant role in promoting the benefits of this particular rotation, which has developed a strong reputation for preparing hospital staff to administer care to people from different cultural backgrounds.

Figure 1. Map of Cameroon and location of Saint-Luc Hospital

Saint-Luc hospital

Saint-Luc hospital is situated in Bimengue, which is part of the Cameroon forest (see Figure 1).The facility is surrounded for 70 miles by wilderness, which provides some protection from the urban violence that is a common problem in many major cities in Central Africa. Saint-Luc hospital is an eight-hour trip from the nearest airport, and the road to the mission—built by German colonizers at the end of the 19th century—is unpaved and full of holes. With just 30 beds, Saint-Luc is a small facility that serves a population of about 20,000 people. No other medical facility is available to the people living in the small villages and tribal communities within the forest. The mission and the hospital were built more than 40 years ago by a Catholic priest of the Spiritan Congregation from Como, Italy. The priest manages all of the organizational and economic affairs of the mission, except for the hospital, which is managed by the not-for-profit organization Don’t Forget Africa (DFA).

Care is provided to patients presenting with a variety of medical issues. Abdominal, obstetric, and urological surgery are routinely performed on patients in need. Patients suffering from other medical problems, such as marsh fever and illness related to intestinal parasites, also receive care at Saint-Luc.

It is difficult to comprehend how the local population received medical care before Saint-Luc was built. Most likely, local midwives and nonmedical individuals functioned as primary caregivers.

Resident selection

For each of the 30 years since the program launched, the fourth- and fifth-year general surgery residents (typically 10 residents) have been given the option to commit a six-month period of their training to providing care at Saint-Luc. The residents themselves determine who will volunteer for this opportunity, and to date 42 residents have participated in this program. Before traveling to Africa, the selected residents spend six months rotating in anesthesia, urology, and obstetrics and gynecology, all of which are key areas of need outside of general surgery for patients living in Cameroon.

Prior to travel, all residents receive the required vaccination against yellow fever; no other vaccination is required. None of the residents have reported significant health problems during or after this experience. A few residents have suffered from short episodes of mild diarrhea (probably bacterial in origin), and from short episodes of fever of unknown origin. At a mean follow-up of 10 years, none of the residents has reported health problems related to his or her experience in Africa.

All resident participants have reported a high level of satisfaction with the experience at Saint-Luc, both from a professional perspective, including improved performance and confidence levels, and from a humanitarian point of view. Participants reported high levels of interaction with the local population, engaging in such social activities as sharing meals, playing soccer, exchanging articles of clothing, and so on.

After participating in conversations with the residents, the staff at the University of Rome noted that these physicians appear more mature after their rotations. Before going to Africa, one of the most important expectations for the residents was achieving a large income. After returning from Africa, the major priority for these residents shifted to less finance-driven goals, specifically an interest in helping other people. Luxurious cars, dinners in sophisticated restaurants, or lavish holidays lost their allure in comparison with developing personal relationships and providing optimal care to patients.

The staff of the hospital also has observed a significant improvement in the residents’ clinical abilities, as well as enhancements in their observational and communication skills, which are essential for providing quality care no matter the environment.

Approximately 20 percent of the residents have voluntarily returned to the mission hospital for periods of two to six months in order to provide surgical care to those in need, as well as to help mentor other residents working in the region. Funds for their renewed mission work are provided by DFA.

Gianluca de Vito, MD, the first surgical resident to journey to Saint-Luc (and a co-author of this article), decided to remain and work in Africa. He married a journalist from Holland who also was working in the region. Dr. de Vito has spent more than 25 years providing medical care to people in remote regions of Africa.

The residents’ role

Resident participants live in the mission and are on duty virtually 24 hours a day. Residents see all the admissions and visits to Saint-Luc, and they rely on local nurses to assist in communicating with patients and their families. Because Cameroon became a French colony after World War I, many Cameroonians speak broken French peppered with many dialectal phrases. Nurses also help participants enhance their knowledge base regarding some of the more common diseases affecting the local population, which were described earlier in this article.

Each resident member of the program (mean age 28 years) has performed an average of 50 major and 80 minor operations. The complication rate has been very low—less than 3 percent. The low complication rate is generally attributed to the young age and good health of the individuals who are able to make the journey to Saint-Luc.

Local nurses have assisted in the delivery of babies, about 20 deliveries per month. Residents are involved in deliveries only if complications arise or if a cesarean section is needed (5 percent of the cases). Typically, the residents see an average of 500 patients in the outpatient clinic during the six-month period. Most of the surgical procedures relate to draining of abscesses, repair of trauma wounds, bone fractures, hernia, thyroidectomy, hysterectomy, and bowel obstruction. Most are elective or semi-elective procedures, but a number of urgent operations for strangulated hernia or bowel obstruction also have been successfully performed.

The residents follow up with all patients in the hospital on daily rounds. They are typically the only physicians on site, so they must provide care for all medical problems. All commonly used drugs, such as oral and intravenous antibiotics, intravenous fluids, analgesics, aspirin, proton pump inhibitors, cortisone, quinine, artesumate, and so on, are available at Saint-Luc. Each resident also brings a supply of pharmaceuticals and other supplies, such as suture materials and meshes for hernia repair.

No anesthesiologists are on site, so the resident administers anesthesia in addition to performing the operation. The local nurses have experience with intravenous analgesia, such as morphine and fentanyl. Most operations are performed using local anesthesia. For more difficult cases—strangulated hernia, hysterectomy, thyroidectomy, and bowel obstruction—intravenous analgesia is added to local anesthesia.

Patient satisfaction

The local people have been very satisfied with the care they have received from the residents at the Saint-Luc hospital. Patients typically show faith in the residents and are thankful for the care they receive. Much of this positive relationship is a result of the continuous social contact the residents have with the local population living around the mission.

The people involved in this work agree that this is a rewarding experience, one that reminds us of the meaning and the beauty of being a surgeon and what a privilege it is to take care of people in need. A smile or the gift of a wild fruit is often more memorable than a monetary reward.

Italy remains a gateway to the Western world for many immigrants from North Africa and the Middle East. In fact, the number of immigrants from these regions has increased in recent years due to the political instability of both regions. This phenomenon has resulted in various Italian hospitals recognizing the need to address the cultural differences of these immigrant populations.

Future challenges: Funding and rotation decline

Unfortunately, securing funding for our missionary work in Cameroon continues to be a challenge as DFA, our sponsoring organization, relies on private donations. A notable exception is the Italian Episcopal Committee, which recently offered support for a program aimed at improving maternity and infant care. Since the implementation of this program, mortality rates for pregnant women have been dramatically reduced, and there have been no recorded cases of infant mortality.

In addition to funding hurdles, the program faces other challenges related to a reduction in resident participation. Residents have expressed a decreasing interest in the Saint-Luc rotation, which may be attributed to a couple of factors, including the Ebola epidemic of 2014–2015, even though Cameroon was unaffected; the continuous political unrest in the region; and the retirement of Professors Stipa and Cavallaro, co-authors of this article and a leading force behind the success of the Saint-Luc hospital resident rotations. Upon Dr. Cavallaro’s retirement  from his academic position in 2010, he joined Alberto Sciamplicotti, a photographer with the University of Rome, in giving renewed support and energy to a small project initiated by the first residents who worked at the mission. This humanitarian organization continues to work to secure funding to continue this rotation in Africa.

While many debates regarding the ongoing role of Italian physicians who provide care for immigrant populations continue to have a presence in the media, the hospitals and physicians continue to work to meet the needs of these patient populations, with little regard for the patient’s social, economic, and religious background. Our experience in Cameroon continues to serve as a reminder that differences in culture can be overcome by knowledge and friendship.