For my elective I decided to travel to Tanzania. It is a country I've visited before as a tourist and I loved it so much I wanted to go back and see it from another perspective. I arranged a placement with Work the World as they promised to take all of the hassle out of arranging it. It paid off.
My elective was based at Mount Meru Regional Hospital in Arusha. The hospital has some 450 in-patient beds (although this might better represent the number of patients rather than actual beds as described later) and sees 600 out-patients daily. It serves a large population and provides a wide variety of services: A&E, obstetrics and gynaecology, TB and leprosy wards, general surgery including orthopaedics, psychiatry, and physiotherapy among some other departments. It was and is a very busy hospital and is staffed by very few doctors who are assisted by over 180 nurses.
Walking in to the hospital on my first day I was filled with anticipation. I really didn’t know what to expect. Horror stories abound and on your way in, do make you think, “What the hell am I doing here?” So, as I stepped onto the general medical ward to meet the local intern that I would be shadowing, I have to confess, I was a bit nervous. However, the smiling face of Dr D. soon put me at ease. He was really welcoming and willing to show me the ropes. However, it was still set to be a bit of a shock.
The general medical department consists of two wards, one for each sex. Both have approximately 20 beds but on the day I arrived the male ward had over 40 patients. Patients, strangers until that day, are required to share beds. As many as three patients may be in one bed at any one time and the bed itself is a rusty and worn old bed, which may have been donated by the NHS of the 50’s or 60’s. The floors of the ward are bare concrete, which is at least easy to clean. Indeed the cleaning of the floors takes precedent over any ward round that may be about to happen. Doctors waiting patiently until the cleaners have finished. On a more positive note every bed does have a mosquito net; although in all my time there I never once saw them down. I was informed that they are lowered later in the evening.
So having been shown the wards we started a ward round, cleaners now out of the way. It did not take long for the challenges facing these doctors and nurses to become apparent. Many of the patients had malaria and one was suffering a case of cerebral malaria which made him quite aggressive and difficult to control (this duty left to other patients rather than medical staff). Two other patients had tetanus, a condition I had never seen before, probably reflecting the success of the UK’s vaccination program started in the 1960’s. On average there are only 6 cases of tetanus a year in the UK and on my first day on the ward I was confronted with two cases and they were not to be the last. Other patients on the ward had TB or HIV/AIDS but a significant number remained undiagnosed due to a lack of diagnostic testing facilities and equipment. Investigations were routinely ordered by the doctors but this did not ensure either the collection of samples or the processing of results.
There were limited facilities for cultures so infections were generally diagnosed and treated on clinical suspicion alone. Blood testing was available but the lab was not always open and needles and collection tubes were in short supply. Tests were only ordered when the need was great and indeed there was some way of paying for them. Nearly all medical treatment is paid for by the patient or the patient’s family. The hospital does receive some government funding but it is incredibly limited. If we think we have problems in the NHS in the UK, they pale in comparison.
On one occasion in my second week, when I was on the female ward, the hospital received two lumbar puncture kits. There were five patients on the ward that were either showing signs of encephalitis or meningitis who had been waiting some time (over a week in one case) for the appropriate investigations to be done. So, I watched as the two kits were used to obtain samples from all five of the patients. Not ideal but it was the only way these women were going to get the investigations they required. This was just one of the occasions when it became abundantly clear to me how lucky we are in the UK, where we have cupboards full of this sort of equipment. We all take for granted that the equipment we need will be available, indeed that there will be a surplus for us clumsy or ill-practiced medical students. It could have been very easy for me to be shocked or horrified at what I was seeing and hearing but on the contrary I was very impressed by the way the doctors kept their heads when faced with these very difficult circumstances.
One department that did seem to work well was radiology. Requests for x-rays were promptly acted upon and reports, although brief, were nearly always available as quickly. Unlike in the UK where we have become accustom to the idea of viewing x-rays on the computer the x-rays in this hospital were still provided on film. There were no light-boxes to view them on, but luckily Tanzania is not short of bright sunlight. Given the large numbers of pneumonias and TB’s being diagnosed this functioning department proved invaluable.
The lack of adequate diagnostic investigations made diagnosis a significant challenge to the doctors. It was not like in England where you can order a bank of (sometimes unnecessary) investigations which may provide some clues as to a diagnosis. In the Tanzanian hospital the doctors were much more reliant on their clinical acumen. Another factor that only compounded this problem was that very rarely was a consultant or senior registrar to be seen on the wards and so it was the junior staff with the least experience that were making all of the decisions. The wards were overseen by a consultant but in the few weeks that I was on these wards he only came in for the morning meeting a couple of days a week at most and this was primarily to discuss the patients that had died in the preceding few days.
Despite my grim observations the four weeks I spent on the general medical wards were great fun. I felt like part of the team very quickly and was always greeted with a warm smile and a “habari za asabuhi” (good morning in Kiswahili) or “karibu sana” (you are very welcome). The nurses on the wards would act as a translator for me as much as they could when speaking to patients. I was encouraged to examine patients and was able to gain significant experience with conditions that are not as frequently seen in the UK, particularly malaria and TB.
In the remaining two weeks of my placement I spent time in the psychiatric department. This was set to be another massive eye-opener. The department is entirely nurse-led and is run as an out-patient clinic. There are no psychiatrists in the entire hospital and apparently, there are only 12 psychiatrists in the whole country. There was one “mzungu” (white person in Kiswahili) doctor from Holland, who had an interest in psychiatry but who had not yet started her professional training, along with a mzungu psychologist working within the department, but they stayed behind a closed door and were very rarely seen talking to patients.
My supervisor in the department was Sister G. She had over 20 years experience in the provision of psychiatric care but her formal training in the field was very limited. She still had a wealth of knowledge and experience that she was willing to share and that started straight away. She would essentially let me run the clinics as if they were my own. I got to interview all of the patients, suggest diagnoses and treatment plans.
On my first day I was immediately confronted with a very psychotic patient. He had been diagnosed with schizophrenia many years before and was being treated via monthly visits to this clinic. He sat down opposite me and said “shikamoo baba” (a formal greeting in Kiswahili) but that was to be the only straight forward moment within the whole consultation. We asked him how he was coping and he proceeded to tell us about the terrifying hallucinations that he had been experiencing. A hallucination he was actually experiencing as we were talking. It involved hands bursting out of his spine and trying to grab his face. He was often obviously distracted by them as he would often recoil from ‘the hands’.
Another patient that I saw on the same day came in with a ‘rash’ on his hand which I agreed to take a look at. On closer inspection it was obviously not a rash. The ‘rash’ consisted of a series of very deep bite marks, some a lot older than others. When I asked him how he happened to sustain these injuries he calmly explained that often he would see evil spirits flying into his wrists and the bite marks were his attempt to get them out.
This was already unlike anything I had experienced in England, where patients have their symptoms more adequately controlled. In this department floridly psychotic patients were the norm and every day brought with it new surprises.
On other days serving prisoners would be brought into the clinic. Often these prisoners would be in jail for petty crimes but more often than not they were being detained for murder. This was made more worrying as they did not have any guards with them and would often be carrying the machete they had been given to cut the grass. Instead of guards they were minded by more trustworthy prisoners. A common practice in many African countries apparently. Sometimes there would be 3 or 4 prisoners in the room with me at one time and invariably they were not suffering any psychiatric problems. They had learnt that if they faked depression they would be able to get to the hospital where they could more easily see relatives within the grounds as well as pick up a bit of amytriptyline (a tricyclic antidepressant) to help them sleep. This was not something that I was going to argue with when confronted with a murderer.
The department also treated patients with epilepsy, seen as a psychiatric problem rather than a neurological problem within the community in Tanzania. There is still some belief that the seizures are due to some sort of possession of the mind perhaps by spirits or magic. Indeed psychiatric help is often only sought after a traditional healer has been consulted. This is still an important part of the culture and can actually postpone adequate treatment. The fact that epilepsy falls under the remit of psychiatry does have one benefit and that is that the medication is free of charge. Unlike all other departments psychiatric patients receive free medical care.
The medications might have been free but there were very limited choices. Indeed there were only 6 medications used within the department. These were the antipsychotics chlorpromazine and haloperidol, the antiepileptics phenobarbitone and carbamazepine, diazepam, and the tricyclic antidepressant amytriptyline. This did make prescribing very easy but the arsenal of medications that is available in England is no way matched by that in Tanzania. In England when one medication doesn’t quite work or the side effects are too much to cope with then there is often another medication in the same class that can be trialled. In Tanzania however, it is a one size fits all approach to treatment.
When looking through the notes of the patients it became evident these patients had been on these medications for a very long time. In most cases unchanged since their diagnosis. This varies from England where medication reviews happen regularly. This highlighted the fact that the Tanzanian clinic would often just run as a system for repeat prescriptions, with very little time spent reviewing the patient’s symptoms. This meant that in some cases patients were on medications that they no longer needed, as was the case with a 6 year old boy who had a febrile convulsion 3 years earlier and was still being treated with phenobarbitone. More often however the medications prescribed were of insufficient dose to control symptoms. It was unclear whether or not this was a matter of finances or a matter of poor practice. I gave Sister G a copy of the BNF and she agreed that in most cases we could increase the dose of some of the medications. There was a formulary available but it was not used at all so I left my one with Sister G on my departure.
The time I spent in the mental health department was probably the highlight of my elective. It was really hard and challenging work at times but it was an area where I felt I had made a big impact and I felt particularly useful (if only for my BNF). It was a real shame when my time came to an end.
On balance my time in Mount Meru Regional Hospital was brilliant. Although there were some obvious challenges I found everyone, patients, doctors and nurses alike, to be very warm and welcoming. I was encouraged to learn and to help where possible and in many ways it has helped give me some confidence in myself which will stay with me as I embark on my career in England. I hope to get back to Tanzania again later in my career and maybe be a bit more useful. It is a place that will always have a place in my memory and my heart.
And don’t forget that Freddy, the WTW Programme Manager in Arusha, is a BIG Chelsea fan!