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.

It Is Time

The following was submitted by Lauren Haveman, a second-year Medicine-Pediatrics resident on international elective in Arusha, Tanzania, under preceptorship of Steve Swanson, MD.

Interpreting an x-ray

Holding a patient in the hospital

Yesterday I spent the day with an amazing and group of women who run the hospice and palliative care outreach for Selian Hospitals. There are over 4500 men, women, and even some children in four districts around Arusha who are blessed by the services of this outreach.

In a place where life is a constant struggle for so many people and it is all too easy for situations to feel hopeless, it was truly humbling to experience the care and compassion provided to so many people. We visited two Maasai men in their separate bomas (compounds or groupings of homes) in a sprawling mountain village probably less than 20km from Arusha Town but still more than two hours away by truck on a road that is not passable at all when it rains.

Both of these men were on their death beds a few years ago, literally dying from AIDS. One man, who is my age, had a CD4 count of 3 when he was reached by the palliative care team in 2008. Thanks to President Bush's PEPFAR, anti-retrovirals (ARVs) reached Tanzania and many other countries around the world for the first time, and both of these men, though still sick, have made dramatic turn-arounds.

Touched as I was by the new life given to both of these men, I could not stop my heart from breaking for the many people, primarily women and children, who still have no way of protecting themselves from this deadly virus.

The first man we visited was in his 40s, and when he was started on ARVs in 2009, his wife and four children were reportedly tested and found negative. Unfortunately, as I also saw in South Africa, some religious leaders here make claims to be able to cure HIV/AIDS with a cup of medication, prayers, or chants. This man visited the spiritual healer, Babu, whom he believed to be an HIV/AIDS healer, in 2010 and stopped taking his ARVs. In October of 2011 his CD4 count was 48 and he was restarted on ARVs, but in the interim he again became very sick and we can only expect that his viral load was sky high, putting his wife (who was previously negative) at increasingly higher risks of infection.

Sadly, hers was not the only life at risk when this man stopped his medications; according to Maasai culture, he has and will continue to take additional wives, usually very young women chosen by village leaders. He told us yesterday that he now has two wives, but the first has not been tested for HIV since 2009 and his "young wife" (who we estimated to be between 15-17 years old) has not been told that her husband is seropositive because he feels that she is too young to understand.

He also shared with us his fear that if his young wife knows he is sick, she might get scared and tell others in the village the secret. In fact, he had sent her out of the boma when we arrived yesterday so she would not overhear any of our conversation.

This young Maasai girl, who was unable to finish school because it was her time to marry, is unknowingly exposed to the virus every time she sleeps with her husband. She has since had a child who may or may not also have the virus, but we do not know since the child has not been tested, at the father's decision.

In my four weeks working at Selian, Kelly and I admitted two babies with Stage Four HIV infection (the sickest a child can be), neither on ARVs. The first baby was about seven months old and presented with pulmonary tuberculosis, severe thrush, and severe malnutrition with wasting (he was the weight of a healthy newborn in the United States). The mother did not know she was positive.

The second child I met on Monday, a fourteen-month-old female who weighed 5.4 kilograms (the average weight for a healthy three-month-old female). She was too weak to cry, with marasmus and extreme abdominal tenting, and could not hold her head up. Mom told me that she herself was HIV positive and had been on ARVs during pregnancy, but her husband and family abandoned her and she had no resources to feed her child or seek medical care. The infant had not been started on ARVs, and she died three days later.

We also had a sweet seven-year-old little girl who looked about three years old, was known to be seropositive and previously on ARVs. Her mother had stopped her medications more than a year ago because she had gone to see Babu for a cure, but the child has returned to the hospital with severe malnutrition and in desperate need of restarting ARV therapy. I think about the young mother we met at the boma yesterday and how easy it would be for her child to be the next admission.

Interestingly, after I got home from the village yesterday, I opened an e-mail from Dr. Amman, a pediatric ID specialist at UCSF and a man who has been at the forefront of the HIV epidemic since the virus was discovered in San Francisco in the 1980s. He is also the president of an organization called Global Strategies for HIV Prevention and has worked around the world and especially in Africa, advocating for women and children.

I learned that the United States Public Health Service finally released treatment recommendations stating ALL people who are HIV positive should receive ARV treatment: "Antiretroviral treatment is recommended for all HIV-infected individuals."

No longer should we wait for absolute CD4 counts to fall in adults and adolescents or for CD4 counts to fall in young children. However, the World Health Organization's guidelines have not yet changed, and it is these guidelines that shape the ARV policies of most countries around the world, including Tanzania.

What if we did treat every HIV-positive individual with ARVs? Studies show us that transmission rates would fall as viral loads are lowered in infected individuals. We could further reduce the maternal to fetal spread of the virus. The virus would be prevented from mutating into resistant strains if hit hard (and early) by multi-drug therapy. Life-threatening opportunistic infections would be reduced. Infected children would not be as badly plagued by the malnutrition I see here every day. In short, HIV would continue to become a chronic disease instead of a life sentence, transmission could be further reduced, and lives would be saved. This would be an answer to many prayers.

What is stopping us from treating everyone who is HIV positive? For me, the scariest and easiest factor to change is the fact that as a nation and world, contact tracing has never been used in the fight against HIV. Unlike tuberculosis, syphilis, gonorrhea, chlamydia, small pox, SARS, ebola, polio, and other infectious diseases, there is no requirement that a case of HIV be reported in order to trace a person's contacts. Without this measure, there are millions of people in the U.S. and around the world who are HIV positive and do not know it (estimates are that 20% of HIV-positive people in the U.S. do not know they are infected, and up to 90% of infected people are unaware in certain regions of the world). According to the new guidelines, all of these people should be on ARVs now. If universal testing and contact tracing were used, the young mother I met would know she and her child were at risk of HIV. They could be tested and treated now, before they became sick. She could learn how to protect herself from the virus if she were negative and become empowered to advocate for improved heath for both herself and others in the village.

My limited number of years in the medical field have been enough to make me passionate about my responsibility as a doctor to notify and test people who are known contacts of HIV-infected individuals. Unfortunately, while I feel this is my responsibility, I am limited by national and international laws.

It is time for this to change.

As doctors, nurses, and public health providers in an age when HIV/AIDS is a manageable condition, in a time when drugs are available worldwide (though arguably not yet available to all who need them), we are now responsible if the epidemic continues to spread. If we are not willing to do everything we can to stop the spread of the virus--and this includes universal testing and contact tracing--then we are individually and collectively responsible for the millions of people who continue to be unknowingly infected, predominantly women and children.

It is time to change the way we notify, test, and treat people at risk for or infected with HIV. With the resources and knowledge we now have comes the responsibility to do everything we can to put an end to the HIV epidemic. As I prepare to fly back to the United Sates this evening, I find myself wondering, am I at fault if the young mom I met yesterday or her child die of AIDS or related infection, because I did not inform her or allow her to be tested when I could have? Am I responsible for her life and the lives of her children both born and unborn?

Performing a patient exam

Another patient exam at bedside

Lauren and Kelly Bergmann distributing charts on the ward

Writing up a clinic note