The country by Z475Pc6

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									General
Tanzanians are very friendly people- you can expect to hear the word “karibu“
(=welcome) multiple times each day! There are 120+ different tribes and multiple
religious believes and still they don’t have any sort of tribal conflicts- probably
something that the “developed” countries could learn from.
Many of the hospital staff speak English and most of them understand it at least a bit.
Outside of the clinic and especially if you are not working in a touristy town it is a little
harder to communicate. Internet access is available in all major cities and touristy
places, incl. Dar es Salam, Moshi, Arusha, Mbeya and Sumbawanga. At the time that
I was there I couldn’t find internet in Mpanda, but I recently received an email from
one of the doctors there so there might be one now.

Mpanda
Mpanda is a nice, but very rural place- you shouldn’t underestimate this. It is not only
quite a long way to get there, but it is also far away from the kind of environment that
most of us are probably used to. It took me 3 days to get there: day 1: ca. 10- 12
hours from Dar es Salam to Mbeya (on the way back it took me over 15 hours due to
a bus breakdown), day 2: ca. 8 hours from Mbeya to Sumbawanga, day 3: ca. 7-9
hours from Sumbawanga to Mpanda (this road is really VERY rough and you
basically can only use it with a 4WD car). On the way you will have to drive through 2
national parks, thus if you are a little lucky then you will be able to see lots of different
animals and thereby get a gratis safari :-)
During the time I spent in Mpanda I didn’t see any other “mzungu” (=foreigner). You
will be a little curiosity for the locals, which can be a quite funny feeling, and I think it
is probably advisable not to go there alone.
I stayed at the chief doctor’s and his wife’s house as the hotel (that according to the
lonely planet exists) would have been too far away from the hospital. The Christian
mission which is directly next to the hospital was the place where I was supposed to
stay, but after my arrival I found out that it was already completely booked by locals.
At the house that I stayed there was no running water, but a sink nearby.

Moshi
Beautiful town in the north just situated on the foot of Mount Kilimanjaro. It’s a very
touristy place thus you can enjoy various luxuries like tourist style
restaurants/coffees, plenty of hostels/hotels, nicer roads and even a night club. Moshi
is easily accessible via a pretty good paved road from Dar es Salam. Buses run
several times a day in all different classes (economy, luxury, super deluxe…); it takes
about 7 hours. Additionally, Moshi is close to all main tourist attractions incl. Mt.
Kilimanjaro, Arusha with Arusha National Park and it’s not too far away from the main
Safari places (Serengeti, Ngorongoro Crater amongst others). In Moshi I stayed a
hostel in walking distance from the hospital- I paid about 8 USD per night.

Hospitals
The Rukwa Regional Hospital in Mpanda is of similar standard as the Kilimanjaro
Regional Hospital (=Mawenzi hospital) in Moshi. The only big difference that I
realized is that in Mpanda there’s no running water in the clinic (at least not in the dry
season). Both hospitals basically lack most of the equipment that we take for granted,
e.g. there is only a very limited choice of drugs and no “high-tech” things like EKG
available. As far as I learnt the MSD (medical store department) supplies all the
hospitals with medical equipment. If they close down for any reason or if the
bureaucratic ways were too long then it can easily happen that the hospitals for some
time would run out even of very basic things like gloves, gauze, tapes or IV fluids.
Patients or their relatives are then usually sent to the closest pharmacy in order to
buy these things themselves. But, although there was only very limited amount of
some basic equipment available, I was very positively surprised that drugs for HIV,
TB and Leprosy were available and given for free to the patients.
The set up of the hospital is similar in Mpanda and Moshi (and from my very short
glance into the hospital in Sumbawanga it seems to be the same there): there are
several buildings on a campus. Each building contains a different ward. There are:
female/male internal medicine, female/male surgery, pediatrics (in Moshi divided in
diarrhea and non-diarrhea), psychiatric, rehab, radiology (there is one x-ray and one
ultrasound machine) and a theatre. Additionally there are dental, CTC (center for
disease control= HIV), TB and Leprosy clinics and the outpatient department.
A ward has about 30 beds, and a lot of times there is more then one patient in one
bed. They theoretically have an isolation ward, but I was very frustrated to see that
patients with open TB were lying in the same room like all other patients. I was trying
to change this situation and therefore had several conversations and meetings with
relevant authorities, where amongst other things I was pointing out this issue.
Unfortunately until I had to leave nothing had happened- the bureaucracy can give
you a hard time.
In Mawenzi they recently built a new theatre which was not yet opened by the time
that I was there, but hopefully will open soon. Surgeries are performed either in
Ketamine or spinal anesthesia. Like mentioned before patients cannot be monitored
with EKG and there is no oxygen supply available- no need to mention that there is
no machine for mechanical ventilation. Apart from minor general surgeries there are
mostly gynecologic surgeries performed. Out of the doctors who operate I think that
only one had studied medicine- the rest of the team were well trained nurses.
Unfortunately I don’t have enough experience in the field of surgery, but I am sure
that an experienced surgeon could be of great help both in Mpanda and Moshi.
On the wards, the most common diseases that you will encounter are: malaria,
pneumonia, HIV, TB, UTI, diarrhea and many burn wounds. Diagnosis can
sometimes be pretty hard to obtain. It sounds very romantic to be able to diagnose
solely with your head, hands and stethoscope without standard laboratory tests or
imaging, but it can be very frustrating as well as you cannot always be sure whether
you treat a patient appropriately (e.g. we didn’t administer ASS to patients showing
hemiparesis after an assumed stroke as we couldn’t rule out a hemorrhagic cause.
By this we mistreated ca. 80% of our stroke patients, being aware of the fact, that we
might have killed every 5th patient if we would have given ASS).
 As I am a doctor who only recently graduated from medical school I was working
most of the time on the female or male internal medicine or the obstetrics wards.
Ward rounds are usually performed by one doctor- and also here, a lot of the
“doctors” are trained nurses. He or she has to take care of 30+ patients (as
mentioned above, in many beds there was more then one patient). Thus I thought
that I could contribute most by doing ward rounds. This way the doctors also had
someone they could discuss their theories with and address questions.
On the obstetrics ward the nurses usually delivered the babies and performed an
excellent job. I then took care of the neonates, as there was nobody who would have
done that otherwise. I also educated the nurses how to support newborns if they
show signs of respiratory distress with the limited equipment available.
Once more, you are working with very limited resources and often times I felt
frustrated as I knew many things that I could have done in order to improve a
patient’s condition, but sometimes was just sentenced to observe, being unable to do
anything. On the other hand, I also remembered that sometimes it is in the best
interest of a patient, if you don’t do something; e.g. I prevented one of the doctors
from prescribing Diclofenac for pain relief in a young patient with epigastric pain and
a recent history of hematemesis. Instead, we agreed to empirically treat that patient
with triple therapy for H. pylori. What I am trying to say is, that no matter how limited
your resources might be and how frustrating some of your days will be working under
such circumstances, there is always something positive that you can do!

Just on the side I would like to mention, that in Moshi there also exists another, more
western-style hospital than Mawenzi. It is called KCMC (Kilimanjaro Christian Medical
Center) and there you can find several doctors and medical students from western
countries. It basically looks similar to hospitals that one would expect to find in a
newly industrializing country. It’s receiving a lot of funds from abroad and thus is
much better equipped than Mawenzi. Several of the patients in more severe
conditions were thus referred from Mawenzi to KCMC (e.g. they have an ICU). It
should be mentioned though, that a lot of patients refused this referral as they
weren’t able to financially afford treatment there.
If one would ask me for my humble opinion, then I would say, that your help is more
needed in Mawenzi. During the time that I have worked there, I was the only foreign
doctor and I am convinced that it would be very beneficial if some more doctors-
maybe specialists- would go there in order to support and educate the local staff. On
the other hand, I also met several exchange students who worked in KCMC who told
me how shocked they were to see the conditions there- some of them returned home
earlier as they couldn’t tolerate the situation. So in the end it is your decision where
you want to work, your help is needed anywhere.

Conclusion
I believe that everyone can make a positive contribution, help where it’s most needed
and improve the conditions to some extend. But: don’t underestimate this endeavor!
The medical teams, both in Mpanda and Moshi are extremely friendly and helpful.
They are willing to teach foreigners the guidelines for the treatment of a wide range of
infectious diseases as well as most of them are happy to receive help/advise on other
issues. I am very lucky that I have met so many nice colleagues and that I was able
to work together with them, sharing our ideas and knowledge. I hope that our
friendships will last and that we will be able stay in contact.
However, I think it is quite difficult and not advisable for medical students to go there
unless they are accompanied by a more experienced doctor. You should definitely
have someone who you can talk to and who is able to explain things to you. On the
other hand, if you are together in such a team than I’m sure that you can learn and
do a lot. Although this might sound very simple, it truly is highly beneficial if you have
a broad knowledge and are equipped appropriately- you will be very grateful for
everything. If possible, then you should bring as much of the equipment that you
would need for your work along with you. Don’t forget to bring basic supplies as well!
Additionally, any kind of old equipment that you would be able to collect will also be
of great help (e.g. an old EKG, pulsoxymetry or CTG machine). And -also a very
simple conclusion- the more educated you are the better, i.e. if you go there as an
attending physician you can help most.
I hope that this little report gave you some basic understanding of the conditions in
the Tanzanian hospitals that I worked in- and the way I experienced them- and I wish
you all the best!
I’d also like to cordially thank the HCV team for making my stay possible!

								
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