- a fellow resident or medical student thinking "Should I do my International Rotation in Tanzania?"
- or a faculty member thinking "Emily, you should be spending more time talking about your experience at the hospital"
- or my distant relative motivated by guilt, worrying about my well-being and thinking "how am I related to you, I would never associate with such impulsive travel plans and decision making."
Recently in Partner Site: Tanzania Category
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.
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
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
The following was submitted by Kelly Bergmann, a second-year pediatric resident on service in Arusha, Tanzania, under the preceptorship of Steve Swanson, MD
Kelly Bergmann cares for a patient on the wards at Selian Hospital in Arusha, Tanzania
On the eve of returning to Minnesota after five weeks in Tanzania, my impressions of my time here are mixed. On one hand I'm excited to go back home and see family and friends. But on the other hand, I will miss those friends that I've made, the people, the culture.
Most of all, it's the children in the hospital that I will miss, many of whom were staring death in the face and courageously took on each day with a smile. Their smiles brought joy to my heart and hope for their future, despite the limitation of medical resources and care that we could provide.
Selian Hospital, in my brief experience, does what it can with limited resources. It is difficult to get reliable lab tests and ultrasound reports. The x-ray machine, bilirubin lights and neonatal warmer work only intermittently. Vitals are taken once a day on the ward, usually by our team as we make rounds. Family members provide food for their malnourished children, but if they don't have money for food, the children aren't able to eat.
Just down the road from Selian is one of the top five hospitals in the country, Arusha Lutheran Medical Center. ALMC is actually a partner with Selian, and much of their profit is subsidized to help provide reduced-cost services at Selian.
ALMC is what I hope Selian will become one day: a beautiful new facility with resources that would rival some hospitals in the U.S. IV fluids can be appropriately administered, labs are reliable, x-rays are good quality, neonates can consistently be kept warm. Just a mile away from each other, these two hospitals are worlds apart.
I will miss Tanzania and the serenity I found amidst the sometimes chaotic day-to-day life. Most of all I will miss the children and their smiling faces.
Joshua, who loved having his picture taken
I will miss Faratha, a 7 year-old girl with AIDS whose smile was so beautiful. I will miss Joshua, a 4 year-old with kwashiorkor who finally smiled at me after about a week. Most of all, I will miss Helena, a 4 year-old with kwashiorkor. I took care of her for almost two weeks and never saw her smile, but I imagine it stretching from ear-to-ear, lighting up a room--the glimmer in her eye as she finally has the strength to smile. No, I never did see her smile.
But that is what keeps me coming back, knowing that someday soon, she will feel happiness again.
Another patient at Selian looks out the window beside her hospital bed
Kilimanjaro, as seen from Mount Meru
Today was a regular day on the pediatric wards at Selian Hospital in Arusha, TZ......
The day began with a Continuing Medical Education given by the palliative care teams at the hospital. In the middle of rounds, a nurse informed us about a very ill child that had been brought to the outpatient clinic.
We rushed to the clinic, where we found an infant apneic. At this hospital, the nurses have minimal pediatric or neonatal resuscitation training, so nothing had been done. Quickly we
began bagging the child, found otherwise good vitals, and obtained a history.
A one-week-old boy, born at home without any prenatal care, was doing well until a few days ago, when he began to have fevers and had a seizure today.
The family initially presented to an outpatient clinic, where the child was given oral amoxicillin (a capsule of amoxicillin was opened and given to the child orally) without any improvement.
The child had a strong pulse, good chest rise with bagging but was coughing. Bulb suctioning resulted in the removal of about 2-4 ml of pink fluid, which was thought to be not blood but the amoxicillin that the child was aspirating.
There was no oxygen available in the outpatient clinic, so the child was taken (while ambu bagging) to the pediatric ICU. Oxygen via nasal cannula was started, and the child began to breath spontaneously.
The child was found to be hypothermic and there is no incubator so the mother was instructed to place the child in direct contact with her own skin. After this his vitals stabilized.
We started empiric treatment for meningitis (without an LP or blood cultures, because neither is available or reliable at the hospital) but first taught the ICU nurse how to dilute a vial of 250mg of ceftriaxone into 150mg doses, and then instructed how to mix D5NS and D5W to make D5 ½ NS for maintenance IV fluids.
Then back to rounds.
Doing well here in TZ, have one more month before coming home.. Happy Holidays, everyone!