Medicine in Tanzania

It has been a difficult week on the medicine service at Muhimbili Hospital, Tanzania’s largest hospital. I’ve been doing rounds with the medical team every Tuesday and Friday morning for the past three weeks. It’s generally similar to medical rounds in the States. Our team consists of a 1st year resident, called an ‘intern’, a 2nd year resident, called a ‘registrar’, a supervising physician, and myself. We spend about 5-10 minutes at the bedside of each patient. The intern or registrar presents the case by giving a 1-2 minute overview. Then, we’ll ask the patient additional questions, discuss the case, and decide on a diagnosis and plan of action.

The medicine practiced here is quite different from the medicine I’d learned in Seattle. Not only are many of the cases and diagnoses different (many things here we don’t see in the US), but also the ability to work up the patient is limited, particularly with laboratory tests. Basic laboratory tests takes about 3 to 5 days from the time the sample is taken to the time the results are returned to the doctor. Similar lab tests in Seattle would take about 3-6 hours, depending on the test. The supervising physician recently said, “There is little point to getting serum electrolytes when it takes 3 days for the results to return. What would you do with the results at that point?” Electrolytes are routinely drawn each morning on hospitalized patients in the US, so corrections can be made rather quickly.

The physical conditions in the hospital are dilapidated, to say the least. The medicine ward is a row of beds along a long wall of open windows. None of the windows have screens and most of them having missing panes of glass. The beds are about 2 feet apart with a thin mattress and bloodstained sheets. There are no electricity outlets, oxygen tanks, or monitors. A basic ‘pulse-ox’ machine (measures pulse and oxygen saturation) is simply not available. The only piece of equipment they have is a sphygmomanometer, to measure blood pressure. In addition, patients are required to pay for their lab tests and some basic medications. A patient must rely on relatives to bring food, but there is a back up plan if patients don’t have any visiting relatives. I’ve already concluded that having a relative who visits the patient is probably the patient’s best prognostic factor.

This week we had a particularly difficult case. On Tuesday, our first patient had a distended abdomen and was clearly in a bit of distress. She was an older diabetic with signs of diabetic retinopathy (some mild blindness), and we thought she was probably in acute renal failure. I mentally ran through the series of lab tests we might order in Seattle. Then, I realized none of these lab tests would be completed quickly, and we shouldn’t wait 3 to 4 days for lab results with this patient. There is no intensive care unit in Tanzania. In order to manage this patient properly, we need to know the status of her kidneys, liver, and pancreas, at least, all of which require lab tests. We probably looked somewhat befuddled, because she looked up at us and said, “so what are we going to do next?” An ultrasound of her kidney would take days and dialysis of her blood was not even an option. We gave her more fluids and ordered the lab tests.

Friday morning the first bed was empty. “She died on Wednesday”, the registrar said. “Did you get the lab results?” I wanted to know what happened for when we face this again. “Well, you see, the problem is paying”, he said, “She had no relatives here to pay for the tests”. So this patient, who probably would not have died if she came to the hospital in Seattle, died because the lab couldn’t turn results around any faster than 3 days and because there were no family members to pay for the results. We never had a diagnosis or cause of death for this patient. It was completely unacceptable in my Western opinion.

This patient didn’t need to die. It really wasn’t her turn. The lack of proper medical care and testing, by my team, made her death even worse. I was pissed off and kicking myself the rest of the day. I went through the case over and over in my head trying to figure out what we should have done differently. No tangible answers.

I suppose over the next 9 months I’ll become more comfortable practicing medicine without any short-term lab results. As for now, it’s rather difficult.

paul

Zanzibar!

I took the 2 hours ferry from Dar on Friday and met up with Laura in the early evening in Stone Town at a bar called Mercury’s, named after Freddie Mercury, the lead singer of Queen who was born on Zanzibar. We were driven out to Janbiani Beach and the Blue Oyster Hotel on the southeast part of the island. The drive was about an hour, and with Zanzibar style driving is enough time to have about 6 major heart palpitations because there are no street lines and you’re sure he’s either going to hit the bicyclist on the road or the oncoming car. That night we caught up on each other’s lives and ate at the restaurant (kingfish breaded with coconut).

The next morning we were amazing at the beach before us. It was beautiful to be able to look out upon the vast and calm Indian Ocean. The tide was out and the women were harvesting seaweed patches. After finishing breakfast, we headed out on a dhow boat to the barrier reef. A dhow boat is a traditional East African boat made from mango tree wood. We sailed for about 20 minutes and then they dropped anchor. “Okay, you can swim here, over there and up to that boat”, Captain Zappy said. We snorkeled for about an hour looking at all the beautiful coral and tropical fish. My favorite was the angelfish with the long appendage on the dorsal fin. The rest of the afternoon we sat in chairs facing the ocean, watched the tide come in, and read our books. Finally read Joseph Conrad’s “Heart of Darkness”, which is dark.

The next day we did a tour of the spice plantations on the island. A driver took us to the interior of the island, which used to be a major center for producing many of the spices we use for cooking. In fact, Zanzibar is still nicknamed ‘the spice island’. The tour was fantastic and we saw the trees and plants for a great number of spices, many of them appear to be part of the natural ecosystem. Tumeric, lemongrass, ginger, cloves, nutmeg, cinnamon, red and black pepper, coffee, etc. My favorite was the cinnamon tree. The guide took a big slice from the trunk and then passed it around, and it was fantastic. The root, which they cut up, was even more aromatic. It was also a great walk in the countryside and through some local villages. In all, it was a good tour and would have been a really great trip, if it hadn’t been for the tropical rains we encountered after the first half hour. We were soaked and muddy until we returned to the hotel.

That night i had my first taste of Amarula cream, called ‘the spirit of Africa’. This is an after dinner drink that looks and tastes similar to Baileys. However, Amarula is made from a fruit tree that grows in southern and eastern Africa, and is a bit sweet and fruity. Very tasty by itself, but i imagine it would also be delicious with some vanilla ice cream. I again had some tasty fish and a glass of wine for dinner.

Then, on Monday, i was dropped off at the ferry to catch the morning boat back to Dar Es Salaam. There was no time on this trip to walk around Stone Town, so i’ll have to save that for next time - certainly there will be a next time. Arrived back in Dar without problems and had a meeting to discuss HIV research in the afternoon. It's always a challenge to transition from the relaxation imposed by the island. Suppose i’m still transitioning, or perhaps, holding on to a bit of the Zanzibari lifestyle and relaxation.

Really a great, very relaxing weekend. Thanks to Laura for organizing and being such an enjoyable travel companion.

Paul

I arrived in Dar Es Salaam about a week ago after 2 long, but uneventful, flights. They picked me up at the airport and drove me to the project house in the Upanga district of Dar. Several of the housemates came out of their rooms to give me a nice welcome. I was a bit tired, so i unpacked briefly and set up my computer. They have a wireless network connection at the house, so i was able to send off the 30+ emails i wrote during my long plane rides. Then off to bed, since i had meetings schedule for the next morning at 9.

I caught a ride to work, which is only about 2 blocks away, with Paul, a housemate. Paul is from Long Island and has been working with the project for about two years and speaks Swahili very well. Paul appears to run the behind the scenes operations and i've taken to calling him the Godfather. He has a wonderful sense of humor and gets along with everyone well.

The weekend was spent buying some groceries and essentials and getting to know my new work/housemates. Sunday, Priya, Rachel, and I went up north along the coast to a small town called Bogamoyo. Bogamoyo was the capital of the region in the late 19th century until the Germans felt that Dar Es Salaam would have a better port location for their ships. Before that time, Bogamoyo served as a major religious missionary post and was a central locations for sending off the slaves collected from the interior. About half would be used in Africa and most of the rest would go to India and the Arabian peninsula. It is now a pleasant small town that makes dhows (traditional African boats) for fishing.

This week has been a series of small accomplishments. I've acquired a cell phone and have been able to feel a little more grounded with my living situation and life. I'm currently living in a large house with two separate floors. On the ground floor is myself and 2 colleagues, Rachel and Priya. We have individual bedrooms coming off a shared living space (with TV), a dining room and kitchen. Feels a bit like college really. Paul 'the Godfather' and Roland live upstairs with a separate entrance and a similar setup. There is a large wall around the perimeter with a barbed wire fence on top, which has now become the standard for any nice house with 'muzungus' (white people) in the developed world. Sometimes i wonder if they are protecting us from them or them from us.

This week i have been able to learn about the various research projects. I have also been able to get some clinical time with Dr. Mugusi when he runs the ward rounds on the Medicine floor at Muhimbili Hospital (Tanzania's largest hospital). It was been very interesting and education thus far. I'll try to share some more interesting hospital cases and stories in the near future.

Tomorrow, i'm going out to one of the local villages with Mushin, one of the Tanzanian doctors i've befriended, and some others. He sets up a mobile clinic in small, distant villages every Sunday and takes a team of people out to treat the locals. We will take some medications, our stethoscope, and some other basic provisions. It should be great fun to see some patients out in the bush under a tree for a few hours! Should be nice to see some of the countryside as well.

Missing you all tremendously. All for now, paul