Hope reflects on the impact of visiting residents & medical students in Tanzania

Posted with permission from Medicine Global Health Chief, Hope Pogemiller

Habari ya Tumaini

(news from hope)

So, it’s been quite a while since I’ve written.  Life has become quite busy, and I have wanted to be thinking clearly before sitting down to write to everyone again. Today I realized I’m not sure I’m one to think clearly…linearly…  So, I’ll write a little on a more serious note.  Life seems so much more serious when you are freezing in the house with fuzzy socks and heavy sweater shawl in place and with a cup of tea.  (Yes, I know it’s 73 degrees. But, can you really put a number on “cold?”) As the content herein will be serious, I’ll attach a few pictures in a lighter vein. 

I’ve always quite liked sea slugs, and as it is the rainy season, slugs are abundant. One of my pastimes has become stalking slugs and taking pictures in the foliage.

F75 is a dog living near the canteen at Selian who was quite malnourished in January as she was breastfeeding her puppies. We named her after the initial formula fed to children with severe acute malnutrition—F75

In my short time in Arusha, I’ve been impressed with the lasting, positive impact made by the revolving door of residents and medical students at Selian and ALMC. They arrive with eyes wide open and energy. There is a general eagerness to help in addition to learn—many are surprised that they have plenty of knowledge to share with medical trainees.  The knowledge gained when visiting Selian and ALMC extends far beyond the sheer volume and serious medical acuity of patient interactions.  

I watch as people absorb the community-centered culture and are introduced to the medical system headed by a government who has a strong desire to provide affordable care to the vulnerable populations, as well as those in upper socioeconomic status.  This idealism is a laudable goal.  Lack of resources in necessary areas results in a medical system for the vulnerable that seems to limp along at times.  It can be discouraging operating within this context, with a serious lack of trained medical personnel in the country.  I think this is one realm in which international exchange with the many visiting medial personnel can be quite valuable.  

The influx of positive energy and new eyes analyzing dilemmas from clinical cases, to medical systems, to clinical education, promotes increased patient explanation from Tanzanians which spurs creative new ideas and approaches that help in the brainstorming process that can “fight the unbeatable foe.”   This truly helps to subdue that nagging feeling that your team is simply “rearranging deck chairs on the Titanic.”

 

One of the planes was owned by Wings of Hope previously… but I found the tail comforting ;)

View from one of my flights with the flying medical service to transport patients from the rural areas of Tanzania to a hospital. The pink dots are flamingos.

Another view from the plane

On a more personal note, friendships form quickly here, and many of them continue after resident/med student departures.  Likewise, it’s been very encouraging to find consultants in the US who are happy to help with tricky cases despite the lab and imaging limitations.  Forging friendships and professional relationships between hospitals in Tanzania and between specialists across countries is one path to a brighter future in the realm of medicine. 

One of my favorite people from New Zealand posing with me in the matching skirts we had made

My favorite New Zealand couple with me at a fabulous Ethiopian restaurant

I feel honored to work with so many Tanzanians and expats who are deeply devoted to medicine and the improvement of lives for individuals and the population as a whole.  It is not infrequent to feel incredibly inspired and unbearably frustrated simultaneously.  The roller coaster of life somehow seems more intense here than it might elsewhere.  As in any medical practice, some weeks are much more discouraging than others in terms of patient outcomes.  However, keeping a list of patients who left the hospital or clinic with a clear improvement in health has been invaluable.  As in the US, debriefing with hospital staff and families is cathartic for all parties involved.  

Closing picture of flamingos from a flying medical service to transport run

Hamna shida. Hamna shida (no problem) and other reflections from the Global Health Chief

Posted on behalf of Medicine Global Health Chief, Hope Pogemiller

Greetings once again from A-town! 

The past few weeks have flown by, and it feels like a whirlwind.  Days are filled to the brim, and I quickly slip into sleep each evening under the comforting canopy of mosquito netting. I gaze at the 1 inch hole to my right, reminding myself that is not large enough to permit entrance of the resident African Hedgehog or the domestic mouse/gecko who leaves gifts in my sink every evening.  Hamna shida. Hamna shida (no problem). 

I've grown close to 2 registrars (doctors who have graduated medical school and 1 yr of residency "intern year") and a few interns.  A few of our sicker patients' families wave and greet me with big smiles around the hospital campus.  These patients and their families speak Maasai, and it is always a little search to find a nursing student or aid who speaks both Maasai and Kiswahili to help communicate at the bedside. Thankfully, greetings and warm feelings have never necessitated a common language.  I feel particularly fond of my older patients.  I've been rounding with the Internal Medicine team for the past 2 wks, and we have had a very low census.  We have a few people in their 30s-40s with gastritis or malaria, and then we have people in their 50s-60s with HIV who are on or off of anti-retrovirals and present with clinical pictures consistent with TB or PCP.  The group of patients that I particularly enjoy are those > 65 years old.  The women often have COPD from years of cooking in an enclosed home with smoke. This often leads to cor pulmonale, and they present with heart failure and/or COPD exacerbation.  One patient in her mid 70s was quite ill, but she greeted me each day with the most beautiful, relaxed smile. Each day she would report to me about her status in Maasai, and then we would begin the search for someone who spoke Maasai and Kiswahili.  My patient and her family recognized quickly that speaking to me in Maasai led to perseverance until we interpreted her message all the way to English and addressed her concern.  It is not an expectation that the medical staff update the family/patient each day as in the States with bedside rounds, but the internal medicine registrar with whom I work is particularly devoted. I watch him including the family in conversation and educating the patient whenever possible.  I often watch the family members during rounds and report to him when they seem frustrated or confused. He immediately takes them aside and explains in more detail or asks them what's on their mind.  He has this calm, quiet, comfortably-paced speech that looks to be greatly appreciated by the patients.  This past week I have learned much about the Tanzanian healthcare system and perspectives from this registrar and a few interns.  Motivations for choosing a career in healthcare vary, as in the States.  The unreliable timing and amount of paychecks for doctors is accepted, while steps are taken for improvement in the future.  In the meantime, the majority the doctors and students with whom I'm working have this thirst for knowledge and need to help those around them have an improvement in their lives.  This core desire combined with an intense community spirit is something incredible to witness.  When I am able to contribute in my part, I am instantly enveloped in this community.  It's hard not to feel very grateful for the opportunity to live here for a few months, making the world just a little bit smaller.

We had 20 international expats visiting for a field trip during a class last week, and it was interesting to hear their thoughts and impressions of Selian Hospital.  One doctor noted that it would be easy to know what to do if we only had the resources here.  Discussion with other expats from Minnesota and the graduate of MN residency who began the 2 hospitals in Arusha has covered this territory.  Loads of supplies have arrived at the hospitals in the past, yet they are not found when needed in the process of medical care.  It would be silly to think they would be used exactly in the same manner as in their country of origin. The key is to creatively think through the pathophysiology of the illness at hand and apply resources in unique ways.  It is not too uncommon to hear expats complaining that Tanzanians often have an external locus of control or learned helplessness... not looking to improve situations when barriers to advancement or success are encountered.  I suppose I am am growing more and more certain that human nature is universal.  Culture just wraps up the variety of personalities in any group with different colors, papers, and ribbons.  We had a diabetic patient who took 1 mo of metformin and then did not have access to a refill of her medication (or maybe didn't prioritize it as highly as healthcare providers might).  It is difficult to adhere to a diabetic diet anywhere in the world, but more so in her community.  We were injecting subcutaneous insulin to cover her high blood glucoses, and she was requiring much lower doses after when it was difficult to find food at the hospital.  We found a way to be sure she has food (not all carbs), and we checked her blood glucose three times daily.  One morning she had no blood glucose reading in the chart, and the nurses had not given her her injectable insulin as they had no glucose reading to doublecheck.  We had finished our supply of glucose monitoring strips. The registrar and intern and nurses immediately shook their heads, explaining to me the problem and adding that this is unacceptable.  There are shortages of medicines and supplies at all times, but certain essential supplies and medicines were simply necessary.  The administration of the hospital has a very open door policy, and the intern and registrar walked over to explain the situation. Calls were made, and by the end of the day we had a box of glucose monitoring strips.  Where was the Tanzanian inertia-- the inability of Tanzanians to identify a problem and find a solution?  Experiences like these give hope.  This is the way to future improvements in the system, and the intervention was wholly Tanzanian.  We have nicknamed the exceptional pediatric registrar at Selian Daktari Hamna Shida (Dr. No Problem), as it is his most common phrase.  Instead of panicking and making a ruckus everytime he notes an "opportunity for improvement," he calmly voices his mantra. Hamna Shida. Hamna Shida.  You can see him beginning to brainstorm, and later he can be found in the cafeteria or under a tree with hospital administration discussing the situation and working on a sustainable solution.  Although it might appear at first glance that he is simply dismissing medication and supply shortages, he is carefully working toward improvement with an eye toward sustainability.  People recognize his value, and he is given much respect.  As others follow suite, it is possible to see improvement on the horizon.  Cautious optimism shared among hospital staff.  Cautious optimism allows for perseverance in the face of adversity-- even if the adversity is deeply engrained corruption to the core of the country.  

Ryan and I have been able to try to understand together the current status and future of healthcare at Selian during the beautiful walks to and from Selian each day.  We alternate between learning kiswahili numbers and body parts, greeting fellow Tanzanians sharing the path, and interacting with schoolchildren learning English.  We vary our greetings, trying not to miss anyone...with the responses we receive sounding something like this... "poa, mambo, poa, mambo, jambo, jambo, poa, GIVE ME MY PENCIL!, jambo, jambo... " The spontaneous humor from our neighborhood children never fails to send us chuckling. Creative responses are very appreciated, and we now shout back requests for anything from a book to a bag. Our colleagues from New Zealand have even inquired about the price of a large cow being herded by us on the path.  Some days are more frustrating than inspiring, but one thing we can always count on joyfully unpredictable conversation en route to the hospital each day.

I hope this message finds everyone healthy and in good spirits-- hope

Greenery on the walk to the hospital

The path for walking to the hospital

Mt Meru in the distance

Arusha Lutheran Medical Center Hospital Complex

Hope checking out an x-ray outside the male IM ward

Tanzania awes Ryan Fabrizius (MP4) as he begins his 2 block elective

Posted on behalf of Ryan Fabrizius (MP4)

 

Karibu Jambo from Arusha, Tanzania! 

 

I am so grateful and blessed to be here in this beautiful country with a genuinely lovely people and culture. Prior to starting work at Selian Hospital, I had the wonderful opportunity to see some of Tanzania's true treasures including Zanzibar and the Serengeti National Park. With this introduction to the country, I was still in a sense of awe, a feeling of other-worldly experience at these sights I had seen in pictures but never expected to see first hand. I arrived at Selian Hospital and Arusha Lutheran Medical Center on Monday looking forward to starting the work I came here to do. 

 

Karibu, in Swahili, as many of you know, means welcome. I have already heard it used in a number of contexts, ranging as widely as (paraphrased in English to my understanding)

• "welcome to our country", 
• "you're welcome to drink chai now", 
• "please come into my store and have a look around", 
• "I'll give you a ride on my motorcycle taxi", 
• and as a response to "thank you". 

Though our English word "you're welcome" seems to cover many similar meanings, I have been struck by how frequently this word is used. It could be that I am so obviously a foreigner (not too many 6'8'' bearded Caucasian men in this country) that I am consistently offered a welcome. But I like to think that this offer is an invitation to enter into the community here, to experience what life is like for the people who call Tanzania home, to learn the triumphs and struggles that Tanzanian's experience on a daily basis, to share in the efforts to bring high quality medical care to the community. 

 

I am familiar with the false belief that the complex social and economic problems of the developing world can be solved by benevolent humanitarians from rich countries. I sense the temptation to feel that certain people might "welcome" us foreigners to solve their problems. But I have seen a convincing glimpse of the resilience and commitment of Tanzanians working to build a country with opportunity, fairness, and help for the poor. Their Karibu is not "please rescue us"; it is, to me, "please join us in learning together" and "let us share a commitment to each other". I have seen this particularly in a few of the medical workers in the hospital here, including Joseph, the pediatric registrar at Selian Hospital. 

 

Joseph has completely shattered all my expectations of what local doctors at the government hospital are like. He has a tremendous fund of knowledge about pediatrics, an inspiring compassion towards the children that he treats, and an encouraging drive to learn more in his profession. I will have more to write on him and other local doctors and trainees later.

 

I would like to end with a short story.  During pediatric rounds, we came to a 1 year old who had been admitted with Severe Acute Malnutrition, a terribly common reason for admission at Selian. The child had been transitioned from the initial F-75 refeeding formula to F-100, showing good tolerance of the formula and some increase in weight. Though the child was still in need of at least a few more days of refeeding in a hospital setting, to assure that he had no complications (such as return of edema, refeeding syndrome, or infection), the mother was requesting to leave the hospital. Fortunately, care of children under the age of five years old is covered by the government (not including certain medications that must be bought at outside pharmacies), so it did not make any sense to me why the mother was requesting to leave. 

 

When I asked Joseph about why they wanted to leave so prematurely, he responded that "if the child stays, the mother cannot eat". There is no food service for patients (other than refeeding formulas for those with malnutrition) or families at the hospital, so they must provide their own, which is extremely difficult for families coming from far distances. When I expressed my awe at the terrible situation, he responded "welcome to Tanzania". 

 

It would be easy to take this as a fatalistic declaration of the state of health care and social determinants in this country, however, that is not how I took it. I watched as he and the medical team came up with a plan together to assure the ongoing treatment of the child without leaving the mother to have to choose between her health and her child's. In this situation, I began to catch a glimpse of the awful reality of poverty, but a ray of hope in the commitment of people like Joseph in coming up with solutions. 

 

This "welcome to Tanzania" said to me: this is the current state of things, but we are already fighting to make it better.

Jambo from East Africa - Emily Hall in Tanzania

Blog Post written by Emily Hall, DO, 3rd Year Pediatric Resident

Jambo from East Africa!

I have spent the first few weeks in Arusha, Tanzania settling in and acquainting myself with the resources, medical facilities, and the community. As true with all my adventures abroad--this has not been what I expected, but equally holds exciting potential and opportunity. In future posts I hope to tell more tales of adventures. However, before things get too exciting...let me explain my perspective of life here in Arusha so if you are considering this as an International Elective you will know a bit of what to expect.

Danielle (another U of MN Pediatric Resident who most of you know) and I initially started our work at Arusha Lutheran Medical Centre, which is located in downtown Arusha and offers more specialty hospital and outpatient clinic care. They have a small NICU which was impressive to tour and have a total of 2 pediatricians on staff in addition to a pediatric registrar. In contrast, we observed and in the past few weeks have found our place at the Council Designated Hospital also known as Selian Lutheran Hospital (subtle name difference to the former mentioned). This hospital is in a semi-rural location in a village just outside Arusha serving both Maasai, Waarusha tribes, as well as people of Arusha. We walk to the hospital with beautiful views of Mt. Meru along the path. (see photo below) The resources here are limited in comparison to the Arusha Lutheran Medical Centre.

Mt Meru

We have been working with two Tanzanian trainees in pediatrics; one of which received his medical training in China the other from Dar es Salaam, Tanzania. Our primary physician contact here is from Australia; she has been a truly wonderful mentor. We round with two nurses and the four of us trainees. Together we have been discussing and collaborating on patient management decisions with particular consideration of differing International Guidelines of management and factors relating to a resource limited setting. This type of work and learning environment has taken a few weeks to develop, but has recently started to come together in an exciting and highly educational format. Later in the week the physician from Australia has been joining us--by this time we have had some autonomy to make decisions and can discuss in more details questions or concerns regarding patient care that have been debated in her absence. Additional training opportunities have included pediatric HIV clinic, pediatric general clinic, and serving at rural outreach clinics.

There have been several very interesting patients and cases, some of which are still a bit of a mystery. Perhaps in the coming weeks Danielle or I can write about one or two interesting patients to give you a taste of the variety of medicine and the diagnostic approach here at Selian.

Arusha provides quite the balance of work and fun. There are limitless things to do in the city and in the country. It is my hope in the coming weeks we can provide a bit of insight on both the medical and culture opportunities we have explored.

Until then, wishing you all well in Minnesota or wherever this missive finds you.

Emily Hall, DO, PL-3

U of MN Pediatric Resident