Machame Hospital, Machame, Tanzania
17th July 2006 – 28th August 2006
I spent my whole elective period of 6 weeks at Machame Hospital, Tanzania.
My decision on this location was a tough one. I was also keen to go to Canada.
I based my final decision on the fact that I had this 6 week opportunity to
observe and be part of a health care system far removed from what I knew.
Although I like to think I may be able to offer my skills as a doctor in a
country not as fortunate or advanced in terms of western medicine it’s
difficult to predict what I’ll be doing in the future so I decided to take this
opportunity to go somewhere less developed than the UK.
I have travelled to a few continents in the past but had never be to Africa. I
choose Tanzania because I knew it was one of the poorest countries in the
world (5th poorest1) and I was interested to see this in terms of their health
care. Tanzania is also a politically and civilly peaceful country which provides
reassurance to me (and my parents!). I spent for elective with fellow Dundee
student Kate Hunter.
Tanzania is the biggest (land area) among the East African countries (i.e.
Kenya, Uganda and Tanzania). It has a spectacular landscape consisting of the
Islands and the coastal plains to the east, the inland plains, and the highlands.
It has world famous National parks and Game reserves and the highest
mountain in Africa, Kilimanjaro. Being a keen mountaineer I was very excited
about the prospect of climbing Kilimanjaro!
History behind Tanzania
Before I headed off on my elective I did some reading about Tanzania’s
history which was very interesting and helped me to understand the culture.
Tanzania has been inhabited since the dawn of mankind. Fossilised footprints
were discovered in the 1970s at one of the national parks, Ngorongoro. They
dated back to a family of hominids some 3.75 million years old. There were
many aboriginal tribes which were assimilated by newcomers. One tribe that
still exists today is the Hadzabe people. They are hunter-gathers who
communicate in an interesting language consisting of “clicks”.
In 1886 there was an Anglo-German Agreement where Germany took nominal
control of Tanganyika (former name of Tanzania). Evidence of this German
influence is still apparent today. Machame Hospital is a missionary hospital
run by the Lutheran denomination and was initially set up by German doctors.
Today there are still strong links with Germany in terms of funding and
visiting doctors and students.
At the end of WWI Tanganyika was under British rule. Tanganyika
Independence with officially proclaimed on December 9, 1961. Under the Act
of Union, in 1964, Tanganyika and Zanzibar united to become the United
Republic of Tanzania. Despite this union Zanzibar retains political and
economic autonomy with its own president and judicial system.
Since the 1960s Tanzania has moved from a one party state, of a socialist
model to a multi-party democracy. There is a presidential system that elects
a prime minister and cabinet from a National Assembly. The president and
National Assembly are voted for every five years. From speaking to people
during my time in Tanzania there is a high political awareness and a
reasonable turn out to elections (better than Britain anyway!). Over the past
40 years there has been both Christian and Islamic presidents which may be
part of the reason why there is political rest and unity.
Religion; 45% Muslim, 45% Christian and 10% indigenous beliefs
Population: Mainland--34.57 million. Zanzibar--1 million (est.).
Language: Kiswahili (official), English and 127 listed living tribal languages
Education: Attendance--74% (primary). Literacy--67%.
Health: Infant mortality rate--98/1,000.
Life expectancy--50 years.
Work force: Agriculture--80%; industry, commerce, government--20%.2
The health care system in Tanzania consists mainly of governmental and
religious/voluntary run services though more recently private services have
been increasing. This may be partly due to the amendment of the Private
Hospital (Regulation) Act, 1977, which had formally banned profit making
through private health services.
HEALTH FACILITIES 20003
Govt. Parastatal Vol/Rel Private Others
Consultancy/Specialized 4 2 2 0 -
Regional Hospitals 17 0 0 0 -
District Hospitals 55 0 13 0 -
Other Hospitals 2 6 56 20 2
Health Centres 409 6 48 16 -
Dispensaries 2450 202 612 663 28
Specialized Clinics 75 0 4 22 -
Nursing Homes 0 0 0 6 -
Private Laboratories 18 3 9 184 -
Private X-Ray Units 5 3 2 16 1
Since 70% of the population live in rural areas there is an emphasis on the
number of dispensaries and health centres. These are often run by nurses
and/or clinical officers and therefore a large number of the population may
never by seen by a doctor. With my experience at a rural dispensary I visited
and talking to patients I was able to appreciate the difficulties faced by the
patients in terms of transport to dispensaries and bigger hospitals. People
will have to walk for several days before even reaching any form of public
transport. This obviously has problems in terms of late presentation of
illnesses or problems with health surveillance such as antenatal care.
Health care training
There are 4 medical schools in Tanzania. Medical training starts at a clinical
officer training centre with 3 years clinical and theoretical teaching to
become a Clinical Officer. After a few years working as a clinical officer they
can then enrol in a medical school to become a “specialist” doctor. Most
doctors in Tanzania, in my experience, have a specialist interest they spend
most of their time working in but also have good knowledge and skills in many
other areas of medicine. This is a reflection of the limited number of doctors
within a hospital so if a patient needs treated and a referral to another
hospital is not an option then the doctor will do what he/she can to treat
them. At the start of my placement I would often get confused by the
diversity of the doctor’s specialities. For example the “paediatric doctor”
would often take the adult medical ward rounds and I also assisted for him in
a caesarean section and a few minor surgical procedures.
Clinical officers form an important foundation of medical care in Tanzania
especially as there is a lack of doctors. They learn the same clinical skills as
medical students in the UK though there is an apparent gap in their basic
Frequent causes of attendance at health facilities in Tanzania (All ages) 4
SNo. Disease % of all diagnoses
1. Malaria 36.01
2. Upper Respiratory Tract Infection 12.40
3. Diarrhoea 6.60
4. Pneumonia 4.70
5. Intestinal Worms 4.10
6. Eye Infections 3.90
7. Skin Infections 3.50
8. Minor Surgery 2.20
9. Anaemia 2.20
10. Pregnancy Normal 2.00
Leading causes of death in hospital in Tanzania (5 years and above)4
SNo. Disease % of all diagnoses
1. Clinical AIDS 15.50
2. Malaria: other than cerebral 15.30
3. Tuberculosis 9.90
4. Malaria: Cerebral 7.30
5. Pneumonia 6.30
6. Diarrhoea 4.70
7. All other anaemia 4.70
8. Cardiac failure 3.70
9. Bacterial Disease 2.80
10. Diarr Dis: Enteric 2.30
11. Ill defined symptoms 0.90
12. All others 26.60
This is information collaborated in 2005 from the Tanzanian Department of
Health. It is similar to the admissions I saw on my placement with malaria,
anaemia and infections being common. Though interestingly hypertension and
strokes were also common in the area I was in but I know in other parts of
Tanzania hypertension is not as prevalent. I think this geographical
difference may be due to diet. The area I stayed was relatively affluent and
there is probably a higher intake of meat and alcohol. I also experienced
first hand their necessity to deep fry and add copious amounts of sugar to
Machame Lutheran Hospital
I spent 6 weeks at Machame hospital located in Northern Tanzania at the
foothills of Mount Kilimanjaro. The nearest large town is Moshi about 30km
away which is well used to visiting “muzungus” (white folk) due to it’s
proximity to Kilimanjaro and great National parks for safari. There is also a
reasonably sized ex-pat community in this area ranging from people who work
with volunteer services to those that have just been taken by life in Tanzania
and wish to stay.
The area around Machame is at an altitude of 1600m and surrounded by lush
rainforest and other interesting flora. The altitude and proximity to the
highest mountain in Africa did mean that the weather could be cool and rainy
but it was worth it for the days it cleared and we had the magnificent view of
Kilimanjaro from our backyard.
Kate and myself at Machame Hospital enjoying our first view of Kilimanjaro
Machame Hospital is a rural mission hospital of the Evangelical Lutheran
Church of Tanzania (ELCT). The ELCT comprises a substantial part of the
religious sector in Tanzania. The Lutheran church first became active in
Tanzania in the 19th Century coinciding with German control and influx. ELCT
is active in health care and education running 20 hospital and more than 160
health centres and dispensaries which equates to 15% of the national health
Machame hospital was started by the Lutheran missionaries at the end of the
19th Century. Today it has an inpatient capacity of 120 beds and can see about
150 outpatients per day. During my placement the hospital seemed relativity
quiet with inpatient numbers ranging from approximately 55 to 90. I am not
entirely sure of the reason for the steady drop in numbers though from
talking to patients and staff transport to the large specialist hospital KCMC
in Moshi is much easier than in the past making it more amenable.
Machame hospital is similar to my experience in a DGH in the UK in terms of
the departments. I was fortunate to spend time in all the departments in the
hospital and witness the services available. This gave me an invaluable overall
picture of the health care service within this area which allowed me to
compare and contrast health care in Tanzania and the UK which I will discuss
more off later. Machame hospital consists of;
- Medical department: includes male, female and private wards totalling
43 beds and an ICU with 4 beds. Medical ward rounds tend to be
carried out be a doctor every few days with the overall running of the
wards being left to nurses and the on-call clinical officer. The patient’s
family are responsible for the personal care of the patient including
washing, moving to avoid bed sores and bringing food. Due to the lack
of a blood bank if a patient requires a transfusion the patient’s family’s
blood is grouped and if appropriate matching the blood is obtained
- Surgical department: consists of male and female wards and 2
theatres. Common operations carried out include thyroidectomy,
prostatectomy and hernia repair. Endoscopy, gastroscopy and
cystoscopy are also performed.
- Paediatric department: Approximately 30 beds available with separate
shared rooms for D&V illness and respiratory infections. Again the
mother/family is responsible for the non-medical care of the child.
Male medical ward Intensive care unit
- Obstetrics and gynaecology: with 42 beds and an antenatal
department. There are approximately 750 deliveries per year of which
about 50 are caesarean sections. Gynaecological problems include
fibroids, cervical cancer - there is no screening programme and is
therefore one of the commonest cancers, infertility – often due to
pelvic inflammatory disease secondary to untreated STDs.
- Pharmacy department: Run by 1 pharmacist and 2 pharmacy
technicians. I spent 3 days in the department which gave me a good
insight into the availability and use of medication. I was given the
responsibility of dispensing medication. I had to give instructions on
taking the medication, warn of any side-effects and any other relevant
information all in Swahili! e.g. “moja asubuhi moja joni baada ya chakula
“ = once in the morning, once in the evening after food.
- Radiology department: There is one radiologist running the
department with 1 stationary and 1 portable (though I never saw it
move) x-ray machine. There is also the use of contrast studies e.g.
barium swallows and IVU and an ultrasound machine. The films are
manually developed and left to dry outside!
- Laboratory: I spent a day in the lab learning how to prepare thick and
thin blood films and looking for parasites including malaria. The lab
carries out minimally investigations which include;
Blood – films, haemoglobin, ESR, WCC and differentials, glucose, cross
Urine – microscopy and biochemistry
Stool – microscopy
Unfortunately blood cultures are no longer carried out due to finances
and lack of skilled technicians. It is a very limited list of investigations
for the clinicians to work with.
- Chapel: Not only for the staff’s daily service there were also numerous
funerals carried out. I was often in a clinic (including HIV clinic) and
would hear the singing from the funeral service.
The hospital also trains clinical officers. There are approximately 150
students in total. The students were sitting their exams when I arrived and
were then off for the summer so unfortunately I did not spend much time
with them to discuss and observe some of their teaching.
The hospital is headed by the doctor in charge (Dr Mvungi, my supervisor)
who is involved with the staffing and general running of the hospital along
with plenty of administrative work and his own clinical work. Other staff
consists of 4 doctors, 5 clinical officers, 44 nurses and 46 other staff
(includes lab staff, pharmacy, accounts department and domestic staff).
Machame hospital relies of patient fees. Patients are billed for everything
that is used from medication to gloves to catheters! Though this is not at full
Some examples of the costs;
- consultation 500 shillings = £0.20
- Bed 600-2000 = £0.40-£0.85
- X-ray 3000 = £1.25
- C-section 17,000 = £7.08
- Blood smear 300 = £0.13
- HIV serology 3100 = £1.29
This may seem like very little money to us though if you bear in mind that the
average wage for a Tanzania equates to about £30/month then paying
hospital fees would have a huge impact on the household budget.
There is a health insurance scheme. Those that work for the government are
entitled to free health care for themselves and 4/5 other members of their
family. There is talk about other employers offering a health insurance
scheme for a nominal payment per month from a person’s wage. But there is a
substantial number of people who do not have an employer, especially in rural
areas. Most people rely on an income from their produce and if harvest is
poor then income is low and any medical hospital will be unaffordable.
Machame hospital also receives generous contributions from abroad,
particularly Germany, Texas and the UK.
I feel I could write plenty about my time at Machame Hospital. I was
fortunate to see and do a considerable amount in my 6 weeks of which a great
deal was so different to what I have done and seen medically in the UK. So I
have written about aspects of my placement which I found particularly
interesting or was just a highlight of my time there.
After a safe arrival on the most dangerous road in Tanzania we were given an
orientation from the Matron. Immediately some of the differences compared
to the UK became apparent such as the scarceness of the facilities and the
bareness of the wards. But also apparent was the friendliness of the staff
and how welcoming they were to us.
Every morning started with devotions in the chapel. I personally am not a
religious person though am very respectful of others religion. The majority of
the staff attended devotions. I found this unity at the start of the day very
comforting and thought that it was a more relaxed way to start than firing
straight into a busy ward round. The clinical officer and nurses would also do
their hand over at the end of church so there was a captive audience there.
Hypertension and Diabetes clinic
On my first day I attended this clinic and I have to admit I was pretty
shocked to come all the way to Africa to sit in on a hypertension clinic. But I
quickly found out that hypertension and diabetes is prevalent in this area of
Tanzania. The first thing I experienced was “African time” i.e. nothing
happens on time. In terms of clinic appointments patients are just given a day
to come as the distance to travel and the unpredictability of transport would
prove impossible for patients to keep appointment times.
I assisted by taking blood pressures, measuring BMIs and helping with health
promotion. This generally consisted of giving advice about their very fatty
and sugary diet and reducing alcohol intake. Lack of exercise is not generally
an issue as for almost everyone walking is the only form of transport.
Medical management is similar to the UK. There is access to a reasonable
selection of antihypertensives and antidiabetic medication though there are
no guidelines (such as the BHF guidelines for starting antihypertensives).
One of the most curious things I noted was that I did not see anyone with
coronary artery disease despite the prevalence of hypertension, diabetes and
strokes. I discussed this with members of staff and a few things I thought
of was perhaps the effects of altitude and exercising at altitude was
protective and also the smoking rates are low. Finding this out may help the
rates of coronary artery disease in western countries!
The prevalence of HIV/AIDS in Tanzania is 7.4%. It varies between regions
but in this region it was similar to the average of 7.4%.
Patients attended for monthly reviews and to get their antiretroviral therapy
if indicated using the WHO guidelines. This service and the medication along
with contraception is free of charge as it is funded for by the government.
Patients must receive pre and post-test counselling and consent must be
obtained to test for HIV. During my placement there was an issue with an
inpatient who had been tested without pre-test counselling and was positive
so the nursing staff requested post-test counselling for the patient. This
obviously brings up many ethical issues such as patient autonomy and consent.
Within the clinic there was an issue of patient confidentiality. There were
several patients within the consulting room at one time. Therefore those
waiting were able to listen to the patient being seen. This may cause the
patient not to divulge as much information to the doctor.
Another issue was that there were 2 brothers (aged approx 10 and 8 years
old) with HIV on therapy who had arrived without a parent or guardian. The
doctor was unable to give them their medication without an adult but sending
them away until they came with an adult would mean they would be without
medication. This again is a very difficult situation, the children did not say
much, but it could be that their parents were too ill(from HIV related
diseases) to attend the clinic. In the end it was communicated to the boys to
come back as soon as possible with their grandmother.
Presenting problems of the patients seen included; suspected TB, fungal skin
infections, drug eruptions to ARTs, hepatitis, heart failure.
Along with ART, if indicated, health promotion advice is given to eat well;
some are given multi-vitamins, managing illnesses early and practicing safe
Out patient department
The OPD is a cross between a GP surgery and A&E. The patients are seen by
the clinical officers who take a history and examine. They can then send
them for investigations (limited tests), prescribe medication or admit if
required. Though I had learnt a little Swahili the clinical officers helped with
translating and so I was able to see a number of patients.
Common presenting conditions included;
- Malaria = often presenting with generalised body weakness (GBW),
arthralgia, headache and fever. All patients with this presentation
would get a blood smear to detect the malaria parasite. Often the
blood film would be negative but the patient would be treated anyway
for “clinical malaria”. The potential severe consequences of malaria are
much greater than taking antimalarials.
- Gastritis/peptic ulcer disease = very common, patients presenting with
heartburn, chest/epigastric pain or anorexia.
- Thrush = often present in teenage girls, given co-trimazole and advice
on hygiene and safe sex.
- Spontaneous abortion
- Post-herpetic neuralgia
- Anaemia – Haemoglobin measured but underlying cause is rarely
investigated. Given ferrous sulphate and/or folate
Medical ward round
There was no set time for the ward rounds to take place and it may be 3 or 4
days between ward rounds and therefore patients being seen by a doctor.
With only basic investigations diagnoses were very much dependent on clinical
findings and a bit of watchful waiting. During this time I had the opportunity
to use my clinical skills and I also had the chance to see a number of common
and not so common clinical signs. The doctor taking the ward rounds would be
interested in my opinion about diagnosis, management and what we would do
back in the UK. This sharing of clinical information helped me to consolidate
my medical knowledge and open up a discussion of disease management which
the doctor would not otherwise had taking the ward round on his own.
A few interesting clinical cases I came across;
72 year old man presents with shortness of breath and tiredness
O/E: very thin, pallor, massive splenomegaly
Ix: Hb 19g/L (1.9g/dL)
Mx: Cross match and transfused 2 units of blood (from relatives)
Feeling a little better but family wanting to move him to KCMC for
DD: for massive splenomegaly and anaemia is large and can be classed into
infective – malaria, leishmaniasis, “tropical splenomegalogy” and
haematological – CML, myelofibrosis, gauchers syndrome.
30 year old female presents with painful swollen left leg
History of HIV taking ART
Husband died of AIDS related disease recently
Has 2 children (I don’t know their HIV status)
O/E: Oedematous lower left leg with multiple bilateral skin lesions – well
demarcated pink lesions ? Kaposi sarcoma
Fungal infection and blackened toe ? necrotic
Mx: Pain relief – diclofenac and paracetamol = no stronger pain relief
I found this case particularly upsetting as this young woman had
distressing pain which probably warranted stronger analgesia than was
available. She has an AIDS defining illness and will spend what remaining
time she has with her children in pain. She has also seen the death of her
husband from this illness. There is little in terms of social support and
palliative care available for this patient and she will have to rely on family
70 year old female presents with poor appetite and generalised
She is a poor historian and possibly confused – her daughter gives most of
O/E: thin, pallor, generalised abdominal pain
Ix: Gastroscopy and abdominal ultrasound
Result: U/S revealed a liver abscess
The cause was not determined as this would be an expensive invasive
technique and would not change the treatment. It is likely to be amoebic
liver abscess which would be treated in the UK also with metronidazole.
22 year old man presents with fever, vomiting and headaches.
O/E: spiking temp – 39.6, dehydrated, no neck stiffness, no abdominal
Ix: Blood smear negative, HIV test positive
Mx: Post-test counselling of HIV status, paracetamol, fluids
This is just a handful of medical cases that I thought had interesting
issues for various reasons. There were cases similar to that in the UK
such as hypertension, strokes, gastritis/peptic ulcer disease. But there
were also a large number of patients with diseases uncommonly seen in the
UK such as malaria and HIV related illnesses. I was interested to learn
more about them and read up on these conditions to fill in gaps of my
The types of surgeries carried out at Machame hospital was dependent on
the doctor’s surgical experience. Dr Mvungi was a trained general surgeon
with a specialist interest in urology. Dr Lema tended to stick to
gynaecological procedures and c-sections. The general physician also
carried out a few c-sections while on-call. It does seem to be a case of
performing what procedures you are comfortable and hopefully capable of
The theatre equipment was basic and temperamental but the surgical
techniques were similar to what I have seen back in the UK. Cleanliness
and sterilisation was at a higher standard than I had anticipated which
was very encouraging and there was no re-using of single use equipment
which I had heard of happening in poorer hospitals.
The biggest and scariest difference I witnessed was the anaesthetic care.
There are very few anaesthetists in Tanzania and the job is carried out by
anaesthetic technicians who have 2-3 years training. In Machame Hospital
there were 2 anaesthetic technicians who are very good at anaesthetic
techniques such as intubations and spinal anaesthetics. But when it comes
to basic sciences such as the physiology of oxygen dissociation curves or
ECG readings their knowledge is lacking. While I was there they received
a new automated machine which included oxygen saturation measurements
but they did not know what the readings equated to. I witnessed a patient
oxygen saturations drop to 50% during a difficult intubation and they did
not seem to realise its significance. A visiting anaesthetist from the
States taught them some basic science in relation to clinical readings and
the importance of ongoing monitoring and recording of these reading
during surgery. Though I do not know how much will be put into practice
purely due to the lack of understanding which is no fault of the
technicians just a training issue.
I assisted in a number of surgeries which I really enjoyed and felt useful
as it’s usually the job of the scrub nurse to also assist. So I think the
scrub nurse was thankful anyway.
While I was at Machame there was a visiting plastic surgeon, Dr
Verheyden (and anaesthetist) from Texas who had arranged to perform
cleft lip and palate surgery. The hospital had advertised this in the
surrounding area and over 20 people (more than expected) showed up. He
managed to perform 10 reconstructions in 1 week and is planning to come
back again soon. The surgeries were performed on both children and
adults which was an unusual situation for Dr Verheyden because in Texas
he only ever carries out cleft lip/palate surgeries on babies or young
children. I saw one case;
26 year old man from Maasi tribe with total cleft lip and palate. His
main problem was not the aesthetic appearance but that people had
difficulty understanding his speech. The result was quite outstanding
and the patient was very happy with it.
School Clinic – Maasi land
This was probably one of the highlights of my placement. I (along with a few
other students) spent 2 days at a school examining 300 six to fifteen year
old children as part of a health surveillance programme to assess the health
of the children which gives an indication of disease prevalence within that
area. It was also an opportunity to diagnose and make recommendations for
further investigation or treatment for any children with an illness as they are
unlikely to attend a hospital due to the distance to travel. Our assessment of
the children comprised of;
- Measurement of height and weight, blood prick – to check haemoglobin
using a colour chart, stool microscopy – each child brought a stool
sample in a little match box!
- It was noted if they wore shoes, had eaten breakfast and if they had
diarrhoea in the last few days. These 3 basic observations can help to
assess the recent health and welfare of the child.
- Examination of scalp, ears, eyes, mouth, lymph glands,
- Communicating in Swahili asking the children if they have pain
anywhere (maumivu), fever (homa), cough (kohoa) and any other
I think well over half of the children had some kind of positive finding on
history and examination such as; tinea capitis, anaemia, goitre, sore eyes,
suspected malaria, TB, schistosomiasis, parasitic infection. I was quite
shocked by the number of children who had wheeze and crackles on
We made recommendations for further testing such as blood smear for
suspected malaria and treatment like antifungals for tinea and vitamin A for
This was a great opportunity to see the children in their own environment at
school and not ill in a paediatric department. It was also interesting to see
the range of problems and illnesses present in this area. I was glad to be able
to put my clinical and communication skills into practice and felt like I was
actually being of help and support to the programme and the children.
Kate and myself examining some of the school children
The Tanzanian Department of Health has come to realise the importance of
antenatal care for the mother and baby. Therefore the government covers
the cost for antenatal care and child surveillance including vaccination
programmes. Despite this there is a surprisingly low uptake particularly
compared to the UK. This is especially seen within the Maasi population. I
think this is due firstly to the fact that Maasi women live so far from
medical care and are hard workers therefore they do not want to leave their
family and cattle to travel for hours/days for a clinic visit. Also Maasi women
tend to have about 6-8 children and live in a community with other Maasi
women who will have had many pregnancies so will be aware of their own
antenatal care and how to cope with many problems which may arise.
The clinic visits were very similar to those I have attended in the UK. They
have a booking visit where the initial history and examination is carried out
and urine and haemoglobin is checked. Then at all other visits they check;
- Blood pressure, signs of oedema, presentation, fetal heart,
- Use of folic acid, nutrients and malaria prophylaxis
The major difference is that ultrasound sound is not used routinely in
antenatal care though its availability means that it is accessible when
complications are suspected.
All women are also tested for HIV status after pre-test counselling. During
one of the clinics I saw a women gravida 6 gestational age 30weeks test
positive for HIV. She was given post-test counselling and advice on
maintaining good health, treating illnesses early and safe sex. She was
commenced on ART and they aim for SVD. I found this difficult to
understand and talked to other midwives about HIV positive mothers delivery
their babies vaginally rather than having a caesarean section. The WHO and
other guidelines recommend delivery by c-section as this decreases the rate
of transmission of the virus from mother to baby. But the midwives were
happy to carry on this way. This mother of 5 being diagnosed with HIV brings
up the ethical issue of telling her family and the testing of her partner and
children. HIV carries a big stigma in Tanzania and often those that are
positive do not tell their partners. Keeping this information from those at
risk is delaying life prolonging treatment therefore this moral issue needs to
be addressed delicately and supportively with all HIV positive patients.
I saw 3 deliveries and 2 Caesarean sections and was able to assist in all with
the supervision of the midwife. I also spent time in the ante and postnatal
wards talking to the mothers and mothers to be.
Assisting in an elective Caesarean section: indication given “large baby”
As I mentioned before the Maasi women live far from any transport or
hospitals. They are a nomad tribe who are very self-sufficient and hard
working. Therefore many Maasi women come to hospital up to 2 months
before they are due to deliver so they can rest. The Maasi women will often
prepare themselves just before labour by fasting, using oils to empty the
bowels, shave their heads and possibly take some traditional medicine to
induce labour. They will keep very quiet and only inform the midwives once
labour is well established. This along with their often high parity means that
delivery is often immanent and the midwives have to prepare quickly.
Pain relief is not given/available for labour. Partners or friends do not attend
the delivery and I feel the midwives can be quite harsh to the patient but
this is just a cultural difference and probably what labour was like in the UK
30-40 years ago.
Oxytocin is often used to help labour progress though there is obviously no
I was able to help with the delivery and immediate care of the baby by drying
and warming them and using hand suction for secretions.
One baby boy who weighed 4.3kg was delivered cyanosed and quiet with an
Apgar at 1 minute of 2. This is a situation in the UK where additional support
would be present. But here there is not that level of speciality and we had to
resuscitate the baby by manually clearing the secretion (by hanging the baby
upside down, laying him head down and using a hand suction device).
Fortunately after 10 minutes Apgar was up to 8.
Skin-to-skin contact and early breast feeding is not instigated by the
midwives. The mothers would be extremely exhausted and cold after labour
and were left to recover without really seeing their baby for about the first
hour. Overall the rate of breast feeding is a high.
Summary; personal development
I feel the elective period is an important part of medical education and for
me will be an invaluable experience of my undergraduate education that I will
always be able to look back on and reflect.
My main academic objectives of the elective was to compare the health care
systems of the UK and here, to learn about tropical medicine and to use my
clinical skills. My personal objectives were to be able to give some help and
support during my time and to think about whether I would work in a
developing country in the future.
I think I definitely achieved these objectives and more, some of which I
hope I have highlighted in this report. In terms of the undergraduate
curriculum I can think of examples of all outcomes. In particularly I had the
opportunity to use my clinical skills (e.g. examination on ward rounds and of
the school children), management decisions (e.g. recommending treatment for
disease for in the school children, discussing management plans with clinical
officers), giving health promotion/disease prevention advice (antenatal care
advice, dietary advice and advise HIV patients on maintaining good health and
treating illness early), communication (with staff, patients and family in
English and Swahili), understanding the cultural and social differences, the
basic science behind malaria, identifying ethical issues (such as lack of
patient confidentiality) and respecting cultural/religious factor, discussing
diagnoses with other staff members and hopefully being part of the health
care team while I was there.
One area I did not have as much exposure to was using my practical skills.
This was not one of my objectives as I was aware of potential risks involved
with some practical procedures such a blood taking and I will have the
opportunity to perform these skills during my 5th year. I was a little
concerned of how I would react and what I would do if I was faced with a
situation where I was depended on to carry practical procedures I was not
comfortable with. Fortunately the hospital was well staffed and anything I
was asked to do I was comfortable with such as giving IM injections or
assisting in surgery.
I have become more appreciative of what we have health care wise and
personally and will try not to take these things for granted in the future.
As I mentioned we were at an ideal location in Tanzania in terms of proximity
to Mount Kilimanjaro and great national parks so we had to take advantage of
As a keen mountaineer I was determined to attempt (and hopefully conquer)
the highest peak in Africa. After much research we found ourselves a guide
and were signed up for a 6 day hike. We decided on the hardest but most
scenic route. This route, Machame, also gave us maximum chance of
acclimatisation. We were well aware of the potential for acute mountain
sickness and one of our group started suffering at around 3000m with
headaches and vomiting. But with team work, persistence and analgesia we all
made it to 5895m – Uhuru peak, the highest part of the mountain. I won’t lie,
the summit push was probably the toughest physical and mental challenge I
have encountered. Walking uphill for 7 hours in the cold and dark and with
50% less oxygen is enough to cause the toughest of characters to break
down. But what a sense of achievement! It was spectacular and well worth it!!
We made it! Highest point in Africa
After our demanding conquest we opted for a relaxing 3 day safari visiting
some of the world’s most outstanding national park. We were able to see a
whole plethora of wildlife in their natural habitat which was just beautiful
and a great finish to a wonderful experience in Tanzania.
There are so many people that helped make this amazing trip but in
Dr Mvungi – head of the hospital and my clinical supervisor
Bob – an American missionary at Machame that made us very welcome and
bought us fresh bread
All the hospital staff for taking time out to show and explain things to us and
make us feel extremely welcome
Kate Hunter for being a great elective companion
And Kate, Matt and Ingvild for helping me up Kilimanjaro!