Side trip to Arusha Lutheran Medical Center

On Friday, I traveled to Arusha to visit the Arusha Lutheran Medical Center. I woke early, took a shared taxi to the bus station and then a bus to Arusha. The trip took about an hour and a half and I was struck by a couple of things. First, traffic as we approached Arusha resembled gridlock. There was a tremendous volume of road traffic, far beyond anything I remembered in the past. I anticipate that this will only increase and without improvements in the roads, traffic will be almost impossible to navigate. Second, Arusha is a lot greener than Moshi, probably as it gets more rain. Lush vegetation, lots of agriculture (including coffee) and many more trees. Finally, Ausha is much larger than Moshi. More high rises, larger area and many more people. It is the major trading hub in the North of Tanzania right on the main road to Kenya. Also, I think its proximity to the National Safari Parks and its location as the UN Center for Rwandan War Crimes spurred its growth.

I arrived around 9:30 and met the director of the medical center, Dr Mark Jacobson. Dr Jacobson is originally from the states, but has been working in Tanzania for over 30 years. He started and ran a hospital outside of Arusha before he moved to start a new center in Arusha. His goal for the center is to demonstrate the state of the art medical care that can take place in Tanzania. The center is gorgeous, very clean and new. We chatted for a bit in his office about working in Tanzania among other things and he made a number of interesting observations.

First, he helped to explain the way that the Tanzanian health care system is structured. It parallels the geographic division of the country. Tanzania is comprised of 21 regions, each with a number of separate districts. There are a total of 200 districts. Each district has its own designated hospital. These are approximately 100 bed hospitals and are staffed by either a medical officer (medical school plus one extra year of training) or an assistant medical officer ( high school plus three years of school). They provide rudimentary surgical care, mostly in the form of caesarian section for obstructed labor. Anesthesia is provided by the medical officer themselves or by nurse anesthetists. More difficult cases are referred to the regional hospitals. Regional hospitals are expected to have at the very least a trained internal medicine doctor, general surgeon, pediatrician and OB/GYN. Unfortunately theses requirements are very rarely met. Cases that the regional hospitals are unable to take care of are sent to one of four tertiary care hospitals. These are Muhimbili in Dar es Salaam, KCMC here in Moshi, Bugando in Mwanza and Mbeya. Tertiary care hospitals have the same requirements of regional hospitals, but are also expected to be staffed by sub-specialists (Urology, ENT, Orthopedics, etc).

Second, a lot of the health care is provided by faith based hospitals in comparison to government hospitals. A lot of times the government will designate a faith based hospital as a district or regional hospital. The estimate is that faith based hospitals provide 50% of the care in Tanzania.

Third, there are 125 qualified surgeons in Tanzania. Most are concentrated in urban areas and only about 50 actually practice. The rest work in administration or oversee foreign programs that can pay a better salary. This represents a type of internal “brain drain” that I had not been exposed to before. That is doctors who stay in their home country but are not providing the services that they are trained for.

Fourth, currently, 40% of the human resources to staff the Tanzanian health care system is present. Much of the gap is met by assistant medical officers (AMO). Again, they have 3 years of training after high school and are very algorithmic in their thinking (ie fever = malaria = treatment). The pros for focusing on AMO education are that they are more likely to live in rural areas and that their skill set is not transferrable outside of Tanzania so they are unlikely to leave the country. Thus the education they are given is much more likely to stay in the country.

Finally, and most interesting from an epidemiological perspective, is that the major health care problems in Tanzania are moving from infectious diseases to non communicable diseases (cancer, heart disease, diabetes, etc.). Strategies to treat malaria, diarrhea, and HIV are very different that those used to combat hypertension, coronary artery disease and diabetes.

After our talk I went down to meet the head of surgery, Dr Paul Kisanga. Dr Kisanga went to med school in Tanzania and did his surgical training in Nairobi, Kenya before returning to Tanzania. He is a true general surgeon and handles pretty much everything that comes his way. Friday was a urology day (not by design) and he had a bunch of cystoscopies as well at a TURP (a removal of the prostate through the urethra). Dr Kisanga talked about how Tanzania only recently allowing privatization of health care had stunted the health care system by forcing many graduates to seek careers outside Tanzania. The surgeons he trained with in Nairobi were able to work in the private sector and were able to make a large sum of money. He says they like to gently rib him about that.

The facilities were very good. They have four rooms and equipment similar to those found in a US operating suite including a C-arm (a portable x-ray machine mostly used by orthopedists), laparoscopic equipment, and new anesthesia machines. When he was using the laparoscopic tower for a cystoscopy, I asked him what would happen if the machine broke. He said that most of the equipment came in the form of donations and they had no real way of repairing the equipment. If something stooped working, their either jury rigged it to work or had to wait until a new piece of equipment was donated. This is a real barrier in providing consistent, quality care.

Many things stuck with me from my visit, but one of the big themes was again to improve the health care system the focus cannot be on just doctors and nurses. Hospitals need administrators to run them and equipment needs bio technicians to maintain them. For health care to be improved, all the pieces in the machinery need to be improved.