Moving to Past Tense

I am now on my way home. The screen in front of me says that we are somewhere above Nova Scotia and will be landing in Boston in a little over an hour. With time on my hands, I look back at the past two weeks and try to see what stands out, as well as predict what will be lasting.

I was not nearly as prolific with my blog as I would have liked. There was more work this time around and less time for contemplative thought.

This past week was pretty busy with getting the project off the ground. In addition to the clinical project, we were interested in figuring out the number and etiology of amputations performed at KCMC and this meant sorting through decaying logs books trying to decipher hand writing nearly as bad as mine. Anthony, Ayesiga (the general surgery resident involved in the project) and I did have a fare well dinner at Salzburger Café on Wednesday night before I left. Anthony is the more laid back and easy going of the two while Ayesiga is a bit more driven and inquisitive. They are a good pair and the conversation ranged from Ayesiga’s skinniness (Anthony says he needs a wife) to the need to have side business projects in Tanzania if you want to make any money as a doctor. During the week, we ran through enrolling patients into the study both in the surgical and orthopedic outpatient clinics. We also submitted our ethical clearance proposal the day I left. All in all, I probably got about 95% of the things I was looking to do accomplished. That is pretty good. Now the project is in Anthony and Ayesiga’s hands and we will see what happened. It would have been fun to have a bit more time for R+R, maybe a trip to a game park or the mountains. Hopefully there will be a next time.

Looking back, a couple of things stand out.

• This trip differed from the last three that I have taken in my role as a researcher. I was no longer a student, there to simply observe and absorb, but rather I had an agenda. My research plan allowed focus and goals, which at the same time brought about frustration and stress. For the project to get underway, it was an absolutely necessity for me to travel and have a face-to-face interaction with the principle players. It helped me to understand the barriers to the project being successful and allowed me to form stronger relationships with my Tanzania colleagues. In my conversation with Mark Jacobsen, among the many paradigm shifts he cited, was the ability to work internationally on more of an interim basis. This is driven by both the proliferation of air travel and that of the Internet and technology. A big part of this trip was not only the amputation project, but also trying to divine how global surgery will play a part in my career. I cannot say I reached any great epiphany, but I certainly did add some data.
• I know I harped on this before, but road traffic has exploded in the past 4 years. I would think that as average income increase, motorbikes and cars become more attainable to more people. This will undoubtedly lead to more road traffic accidents and more gridlock. Both of these will place a strain on Tanzanian’s health and economic growth. For a government already strapped for cash, it is hard to make road improvements a priority. But if no action is taken, I think a crisis looms in the coming years.
• Technology continues to improve in Tanzania. This time around I had a wireless modem, which meant access to the Internet wherever there was a cell signal. This was a huge step up from being chained to Internet cafes. There was also good access to decent wifi around the hospital and medical school.

The wheels just went down and I have to shut my computer. Will offer up any more reflections later.

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.

Morning Report

This past week I have been attending General Surgery Morning Report. Morning report takes between thirty to ninety minutes. It is an opportunity for the young sleep deprived intern to present all the patients admitted over the past 24 hours. Certain cases or management decisions are dissected with varying degrees of civility by both attendings and more senior residents. It is remarkably like morning trauma rounds at the MGH.

The majority of the cases are emergencies admitted through the ER (or casualty as its called over here). Trauma, especially head trauma dominates. This is unfortunately in line with my observation that there are more cars and motorbikes on the roads of Moshi now. As the number of motor vehicles increase and the road safety mechanisms stay the same, the unfortunate outcome is more road trauma. Also, as KCMC is a referral hospital, a lot of these cases are referred in from other hospitals, so that they are already hours to even days out from their accident. The good news is that if they survive to KCMC, they stand a good chance of surviving in the long run.

Another large component of cases are obstructions. Usually small bowel from a hernia or internal band. Sometime a large bowel obstruction from a volvulus (twisting of the large bowel). Also appendicitis and most recently a perforated gastric ulcer from a porter up on Kilimanjaro.

The work up is usually plain x-rays. The hospital does have a CT machine, but an abdominal scan is out of reach for a lot of Tanzanians. Usually the definitive diagnosis comes from an exploratory laparotomy (open surgery) with the ethos “better safe than sorry”.

After the patients are presented and everyone has their say. The cases for the day are discussed and the department breaks for the next 24 hours.

Day One

Kilimanjaro was in full view as I walked to the hospital at 7:30. I again had woken up at 2 and not been able to go back to bed. Jet lag has become very annoying. From 7:30 to 9:30 I sat in on the general surgery morning report. The intern presented all the admissions from the previous 24 hours and got grilled by all above him on the food chain. A lot like trauma rounds at the MGH. Also unfortunately similar were the large number of head injuries from motor vehicle crashes as well as a smattering of bowl obstruction and one diabetic food. The conference dragged on for 2 hours, which prompted a 45-minute drawn out discussion on why the conference was so drawn out.

The rest of the day was spent meeting with department heads and obtaining approval for the project. The reception was for the most part positive and I was impressed by their insistence that the study be approved by the local oversight board (we had already started that process). One amusing bit was that the major cause of amputation was a source of disagreement between the ortho head and the general surgery head. The ortho head was CERTAIN that trauma was the main cause of lower extremity amputation while the general surgery head was POSITIVE that it was due to peripheral vascular disease and diabetes.

Waiting and then meeting took up the bulk of my day and I came home and showered before going to dinner with Dr Kibiki and his 10 year old daughter Mia. Dr Kibiki has risen the ranks of KCMC over the past 10 years. He went to med school in Bulgaria, then returned to KCMC, did his residency and then a PhD. I got to now him when he was a visiting scholar at UVa and came to my house for Thanksgiving dinner 2005. He is now the director of the research institute and a very busy man. We had a nice dinner at the Indo-Italiano restaurant which specializes in the unique pairing of Indian and Italian food (fortunately not on the same plate). Kibiki was very bullish about Tanzania, its growth over the past 10 years and its prospects for the future. I have little reason to doubt him and hope his prediction to be true. He cited shopping malls and movie theatres as evidence of positive growth, but I wonder if that parallels gains made by the Tanzanians living on less than a dollar a day.

Acclimatization

Sunday I continued the trend of waking up at 2, rereading my New Yorker and going through the essential collection of EA Poe. Finally the sun came up and I studied a bit before meeting with Anthony to go over the on line data collection system we are using. This was typical getting things done in Tanzania. First the wifi was out, then the wireless modem was not working so we finally ended up at an internet café with super slow internet and a sticky keyboard that caused Anthony to misenter his password so many times that it locked him out of the system. We concluded the meeting by visiting a friend of a friend who had been stabbed a number of times in the belly, but was doing quite well for it.

Later in the afternoon, I went on the Kilimanjaro hash. A hash is basically a run/walk where you follow a trail of flour around a cross-country course. I managed to pull my hamstring again within the first ten minutes and hobbled trough the beautiful African countryside. The hash ends with beer and potato chips- maybe the adult version of orange slices and water after a soccer game. Met a couple of interesting ex pats that were teaching, involved in local businesses and working in the health care field. This wrapped up around dark and I headed home.