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Mwanza (part I)

2011 June 14

Long overdue, I am finally writing about my trip to Mwanza, Tanzania, which occurred in February and March of this year. I probably hesitated in part because I read Kapuscinski’s Shadow of the Sun during the trip, a book which chronicles 40 years of investigative journalism in Africa with a degree of pathos and style and insight I could never dream of extruding from my brief experience. But never mind: the perfect must not be the enemy of the good.

There is so much to say, so many dimensions to the experience, that organizing it will be a challenge. But this is just why I went: to experience a health care system in its environment, to get to know a little of the people who run it and who it serves. There is far more to know about a society, a place, an organization, than a single article on HIV or clean water or economics could ever successfully convey, and there is no better teacher than experience. I had only a brief experience of only a single place and only a small sample of people—as Kapucinski says, Africa does not exist except as a geographic appellation, so I will not refer to it, but only to Tanzania—and I did not even study very intensively while I was there. But I still feel that I learned more that month than in just about any other.

The executive summary of the medical aspect of my trip is this: patients died on an almost daily basis for lack of tests or treatments that would be entirely routine in Canada. The differences, though, are not just in material resources and burden of disease in the community, but in knowledge and skill levels, institutional organization, educational atmosphere, clinical ethics, and professional attitudes. These things are not so easy to change quickly with sheer money: “making it better,” for me or anybody else, therefore turns out to be a much more complex task than I had previously understood. Nevertheless, this is not a reason to give up: the sheer existence of a large, organized hospital, its multiple professional schools (which do some things better than my own medical school in Canada), and its substantial progress over time are cause for great hope.

My first day

I remember the first day most vividly. I joined the large team rounding on the ward for malnourished children: a gentle, soft-spoken visiting American pediatrician (I’ll call him “Dr. S”) leads a team of perhaps twenty even more soft-spoken Tanzanians, spanning the medical hierarchy from junior students to senior staff, as they proceed from one mother-and-child pair to the next, while a handful of wazungu crane our necks to hear from the back. The student or resident charged to care for a particular patient tells the team leader about the patient, usually focusing on the admission history and physical, and usually too quietly for the rest of the group to hear. They then report the patient’s current symptoms and vitals, and then briefly suggest a plan: often a simple “continue current management”.

We start with a young boy admitted three days ago for fever, diarrhea, and marasmic kwashiorkor (both protein and calorie malnutrition). He is receiving nutritional and fluid supplementation, as well as broad-spectrum antibiotics (ceftriaxone) and antimalarials (quinine). He has lost a little weight today, which is probably good: his protein deficiency meant he couldn’t keep his fluid inside his blood vessels, so it would leak out and puff up all his tissues. The protein he’s now eating is pulling that fluid back into the blood where it belongs, and where it can be urinated out.

But does this boy have enough fluid in active circulation? Dr. S asks one of the interns: “what do you think about this child’s volume status?” The intern peers down at the child for a moment: he sits calmly in his mother’s lap, silently but attentively surveying the sea of studious eyes around him, while his mother—who probably does not speak English, the hospital’s operational language—gazes patiently into the distance. “He is doing well. He is not dehydrated.” Dr. S considers this for a moment, then: “Okay. How did you assess his volume status?” A longer pause. The intern keeps his gaze on the patient, but says nothing. “Does everyone remember the signs of volume depletion that we discussed yesterday?” A few answers gradually emerge from the crowd: pulse rate, skin turgor, tears when crying. With a slight furrow of the brow, Dr. S seems to be mustering his patience. He guides the intern through an examination of the patient, reviewing the ten or so signs to check, as per the oft-referenced WHO guidelines on dehydration in the setting of diarrhea, and moves on to the investigations.

The water was working yesterday, so luckily X-ray film development was available. The X-ray is pulled out from under the patient’s mattress and held up to the window for assessment. It looks normal. Some blood test results, cell counts and examinations for malaria parasites, are back, handwritten by the lab technician on the form that doubles as requisition and report. No malaria parasites are seen. Does anybody know whether the urine analysis and microscopy have been done? More silence. He is uncertain how to respond to this recurrent diffusion of responsibility. He tries, as he tries each day, to nicely reinforce the importance of following up on each item in a patient’s plan, for the student looking after that patient and the intern overseeing the floor.

He reviews the medications. “Sister,” he might go on to say to the headdress-wearing resident in charge of the floor—many of the trainees in this hospital, a partnership between the government and a local Christian organization, are nuns—“now that we have some results back, is there anything you’d like to change in this patient’s management?” It takes a few more Socratic-style questions to reach the conclusion that the quinine is not needed now that malaria has been ruled out. Another principle for Dr. S to reinforce: the provisional diagnosis on admission, and the plan it implies, must be reviewed in light of new information.

My reaction

This was my first impression of the care being provided at Bugando. Whether you have a medical background or not, any of my Western readers, especially those with medical backgrounds, will immediately spot many areas for improvement. But before going any further, I want to emphasize one thing. Taking the average Canadian hospital as one’s default baseline, it is easy to perceive only deficiencies, and I cannot help but describe much of my medical experience in these terms.

I do not wish to minimize the stark reality that Tanzania is too poor to provide the standard of health care we enjoy in Canada, to a population which is significantly more burdened by physical illness than mine. These discrepancies are unacceptable. But I also don’t want to minimize the substantial accomplishments of institution and its staff, either. Of course it’s not as effective as we all might like, but it could also be far, far worse. In a country that only gained its independence in the 1960’s, and which still can only afford to spend less than $15 per person per year on health care, any functioning tertiary care centre of such a size, not to mention all the trainees it successfully churns out, strikes me as an astonishing achievement.

Many of my expatriate colleagues experienced considerable frustration at the discrepancy in quality of care provided in Mwanza compared to what they were accustomed to in New York. I didn’t, though. In part, this was because I tried to keep in mind other comparisons, like between this institution and smaller ones within Tanzania, or between Bugando today vs Bugando in the past — one expat professor who came to visit after a five-year absence reported tremendous, astonishing improvement. I emphasize this point partially out of respect for the many hardworking staff and students of Bugando, but also because I think this crucial perspective means the difference between hope and despair.

The hospital

I came to Mwanza, a lakeside city of a million people, along with my best friend from medical school, to spend a month studying adult and pediatric medicine at Bugando Medical Centre. BMC is a large tertiary referral hospital, covering a region with a population of four million—about the same size as British Columbia. It houses a medical school and multiple postgraduate residency programs, a nursing school, a range of other allied health professional schools, and a Master’s of Public Health program. It has specialists in internal medicine, surgery, pediatrics, obstetrics and gynecology, pathology, and radiology; it has neonatal and adult intensive care units (ICUs). A variety of outpatient clinics each day include general internal medicine, diabetes, HIV, general pediatrics, sickle cell disease, and malnutrition. It is, in short, among the largest and most sophisticated health care institutions in the country.

Physically, the hospital is a simple nine-story concrete tower with about a hundred beds to a floor: ten simple rooms of ten simple beds each. There are a few auxiliary buildings for associated outpatient clinics. It sits atop the highest hill in town and affords a beautiful view of the lake. Most hallways are open to the air. There are many broken windows and the paint is chipped, but the gardens are very well groomed and the floors are generally kept clean. The hospital receives support from some international aid groups like USAID, but the only prominent branding seen anywhere is the AmeriCares logos that decorate most of the custodial equipment.

Also on the hospital grounds were residences and cafeterias for all the various professional students, interns, and residents, plus a stationery store, Internet café and hair salon. All of this is wholly enclosed within a fence, the gates guarded at all times. Among other things, the fence keeps patients from leaving with unpaid bills. While families wait patiently outside the gates for the onset of visiting hours, wazungu like me could stroll right through without a second thought.

Around back, bedsheets dried on long clotheslines. Imposing marabou storks, scavengers nearly as tall as people, hunched and droopy-skinned like old men but approaching majesty when they spread their wings, prowled the garbage heap out back all day long. The security guard would nap under a tree to escape the midday heat.

Up on the wards, patients chat with each other and their cell phones, do their laundry, manage their own medication as prescribed by the doctor and dispensed in batches by the nurse, and spend a lot of time sitting patiently. No monitors or oxygen tubing on the wall, no electric beds. The only privacy available is a single mobile screen for pelvic exams and uncomfortable-looking procedures. On pediatric wards, children share the bed with their mothers, protected by a mosquito net at night.

The hospital, which operates in English, has a long-standing partnership with Weill-Cornell Medical College in New York City, which provides a rotating stable of American residents, mainly to do some teaching for their Tanzanian counterparts. (Through my work with UAEM, I know someone at Cornell, who knows a medical student at Bugando, which is how I ended up there of all places. I’ll say more about this wonderful medical student later.) BMC has also hired a few Cornell grads full-time for long-term contracts, such as Dr. Robert Peck, a very highly respected senior staff member in internal medicine and pediatrics who moved to Mwanza from the USA three years ago. There are also smaller-scale partnerships with the University of Wurzburg (Germany), an Italian pediatric hospital, which also provide a handful of staff for a few months at a time. Medical students from Cornell and Wurzburg and a medical school in Qatar (another partner of Weill-Cornell’s), plus the occasional interloper (like me), also do rotations from time to time. So there is always a mix of complexions in the crowd, though with a largely Swahili-speaking and non-English-speaking population, the Tanzanians do most of the patient care; expatriates (expats) are mostly there to teach or learn. A few Bugando students and residents each year also visit New York and Wurzburg.

Medical training happens in one of the country’s six medical schools. The five-year program involves 2.5 years of classes and 2.5 years of hospital and community rotations. New grads then apply to hospitals to become interns, where they spend a year rotating through every department, managing entire units of up to 50 inpatients, where previously they had been responsible for perhaps two or three at a time. After this, they can practice with a general license; postgraduate speciality training (residency) is optional and usually follows a few years of general practice experience. (Essentially this is how things used to be in Canada, but we’ve made medical school shorter, with more prerequisites, and we’ve eliminated the general rotating internship in favour of immediate and mandatory specialization, with general practice now being counted as a specialty.)

Clinical care

Each weekday at 8:00am, each department has its morning meeting, where the intern on call the previous night presents a few of the cases they saw overnight for discussion and review by the staff and residents. Sometimes there is also an educational lecture. A half-hour tea break follows, and then we reconvene in small teams of 5-10, a mix of residents, interns, and students, for daily rounds: checking in on every patient on our team’s unit (half a floor). Following along with these rounds was the main educational activity of my days.

On that first day, in that one room, I saw children with malnutrition, HIV, TB, malaria, pneumonia, diarrhea, intestinal parasites, and sickle cell disease: it was like something out of a textbook. TB and AIDS were also common among adults. That said, these almost stereotypical diseases of the poor did not by any means drown out everything else. Heart failure, diabetes, peptic ulcer disease, and high blood pressure were very common in adults, at least as much as in Canada, though in contrast to Canada, patients would commonly present only in the late stages: I heard about new admissions for hypertensive encephalopathy or stroke on almost a daily basis. I also saw, with surprising frequency, endomyocardial fibrosis and peripartum cardiomyopathy. Among kids, I saw a lot of unrepaired congenital heart disease, a lot of nephrotic syndrome, and some very large abdominal tumours and lymphomas.

Presented with these conditions, the Bugando clinician has at her disposal the following diagnostic arsenal. One pulse oximeter, one blood pressure cuff, and one thermometer for each fifty-bed unit. A laboratory that can reliably offer culture and microscopy (including CBC, Gram stain, AFB stain, examination for parasites), as well as HIV rapid testing and blood type and ESR. It can sometimes offer tests of electrolytes, kidney function, liver function and enzymes, coagulation profiles, hepatitis serology, lipids, glucose, TSH, albumin and total protein, and CD4 count, when the reagents are in stock. There is also a limited supply of blood glucose strips at the bedside. EKG, ultrasound, and echocardiogram are readily available. X-rays and barium studies can be done as long as there is water to develop the film (which there sometimes isn’t); there is a CT scanner but it has been out of film for some months.

The pharmacy tends to have reliable supplies of the most basic anti-infectives (including for bacterial infections, HIV, TB, malaria, and other parasites), cardiac and renal meds, respiratory meds, Tylenol, diclofenac, steroids, insulin, oral hypglycemics, antacids, phenytoin, Haldol, diazepam, cytotoxics, vitamins, and childhood vaccines. There is a small supply of epinephrine for codes. Supplemental electrolytes, particularly potassium, were scarce while we were there. There is a blood bank which provides reasonable access to whole blood, and can occasionally provide platelets or plasma by special request.

To the best of my knowledge, as far as pediatrics and adult internal medicine are concerned, these lists are more or less exhaustive. For the non-medical readers: certainly everything they stock is very useful, but only the basics are covered.

Sadly, among both children and adults, death was almost a daily occurrence, which the staff appeared to take in stride. If you could magically replace Bugando with a fully-functioning typical Canadian or American hospital, with a quick review of malaria management for the staff, most of these would not have occurred. I’ve already implied a few of the reasons above, though there are many more. Such a magical replacement is not impossible, though it would take a while. How should one proceed?

I’ll pause there. Still to come: educational and professional culture, standards, and skill levels; interactions with western institutions; our accommodations; our Tanzanian and expat peers; visits to other health care facilities nearby; the health care system beyond the hospital… and then there’s everything other than health. The town, the food and drink, the fancy hotels, the minibuses, and especially the people. Stay tuned!

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3 Comments leave one →
  1. 2011 August 2 03:31

    Hi There!

    I just found this entry (after perusing blogs on Mwanza) and absolutely loved it. I’m an Australian who just started working at BMC in the office for development and planning. I hope you don’t mind, but I linked to this post on my blog – it was incredibly well written. Thank you for sharing your experiences.

    Katie

  2. 2011 August 2 03:38

    p.s. I’m looking forward to part 2!

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