Late in the Day

She had been bleeding for weeks. It seems an insignificant afterthought to me now that she never knew her diagnosis. Is it better to die with or without the knowledge of what kills you? She had a few visits to the doctor. What was done for her was unknown. She was pale and confused. Profound blood loss leads to shock: The body prepares itself. Non-essential tissues constrict blood vessels in deference to the brain, heart and other essential organs. The hands and feet are cool and clammy. Ultimately, the brain and the heart have nowhere to turn for oxygen and an inexorable series of events occurs that lead to death. There’s panic, hunger for air and system wide suffocation, then delirium. Is there suffering at this point? It certainly looks like suffering. Flailing arms, retching, gasping….clinging to a loose piece of rock that has detached itself from the face of this earth and only has yet to fall to the ground. We happened upon her when it was late. Late in the day, late in the course of her illness and too late to make a difference. The gasping and the flailing stopped and she lay still. There was nothing notable otherwise. She had been so pale that her now increasingly dusky appearance was barely noticeable. She could have been asleep. Asleep with no breathing..no pulse. A B C’s. Airway, breathing, circulation. IV’s, Fluid, Oxygen, Blood, Epinephine, Atropine…… and the blessed return of pulse, blood pressure and…… breathing. Semi-consciousness returns. Did she have any idea what was happening? Did she have some last fleeting thoughts of her six children. Down again, 1,2,3,4,5,6,7,8…… Breaths, more fluid, more blood, more drugs…….Up again…A continent of vast resources and potential. Motherhood stolen from countless children. Children stolen from countless mothers. She died later that evening. My thoughts returned to a patient in the US with nearly the same condition who survived……. No flailing, retching or gasping. No broken ribs and near death experience. I remember the discussion I had with her about “worst case scenarios”. If she only knew.

Schistosomiasis

August 25, 2008

Over the last few weeks, I have been working with various teams on different hospital wards. The medical service beds are commonly full, (10 beds per room) and so additional beds and patients are placed in the middle of the room (3 can be accommodated). If those are full, they are placed on cots in the hallway. If those fill up, then they double up patients on one bed.

I was surprised that more patients on the medical ward, during my rounds, have complications from schistosomiasis than from HIV. Probably because KCMC has an excellent endoscopy program( an endoscopy costs about $12) and so patients are referred here from other centers. Schistosomiasis (also known as Bilharzia) is the disease caused by a blood born fluke (trematode) of the genus Schistosoma. Snails are the intermediate hosts. Adult schistosome worms were first discovered in an Egyptian patient in 1851 during an autopsy carried out by Dr. Theodore Maximilian Bilharz.

The Medical Ward room I rounded in had 3 female patients with end stage complications from schistosomiasis. They all had liver failure, and I palpated their spleens almost to their pelvis. 2 of them needed endoscopy to coagulate their bleeding esophageal and stomach veins. One patient had 5 liters of fluid drained from her abdomen, and yet she still had such significant ascites, she looked like she was carrying a term pregnancy. All of the women were 20-30 years old.

The Male Medical Ward room had 3 teenage boys, all recovering from bloody vomiting. They also had presumed schistosomiasis. Presumed because the tests required to confirm are prohibitively expensive. At some point once the chronic manifestations occur, there is no cure. It is difficult to predict that point for any given patient.

From the Schistosomiasis Control Initiative (http://www.schisto.org):

Light infections with schistosomiasis can be asymptomatic, and many people may live their lives without knowing they have ever been infected. However, globally, up to 120 million of the estimated 200 million infected people are believed to be symptomatic, and as many as 20 million may well be suffering severe consequences of their infection. The annual deaths associated with schistosomiasis are estimated at 20,000.

The first obvious symptom of infection is blood in the urine (hematuria). Early signs of morbidity which manifest in school age children are anemia, impaired growth, impaired development, poor cognition, and substandard school performance. However none of these signs and symptoms are due solely to schistosomiasis, and so a diagnosis on clinical presentation is difficult.

In terms of Women’s Health, schistosomiasis can wreak havoc on the female genital tract. Diagnosis is made by the presence of schistosome eggs and/or worms in the upper and/or lower genital tracts. Possible consequences include hypogonadism, retarded puberty, infertility, cancer, ectopic pregnancy, anemia due to chronic blood loss, miscarriage and preterm delivery, increased risk for sexually transmitted diseases (including HIV), and vesicovaginal fistula.

The most common method of transmission occurs when humans wade or swim in lakes, ponds and other bodies of fresh water which are infested with the snails. Thus, children and fisherman are at high risk of being infected. The parasite, when present in the water, bores through the skin and enters the bloodstream. The bladder is a favorite site of infestation. And in some endemic areas, a diagnosis is made based on observing blood in a child’s urine.

According to the Carter Center:

Schistosomiasis can be controlled now by one of the great miracle medical discoveries of the 1980s: the oral medicine praziquantel. Now that costs of the medicine have dropped from more than $2 USD per dose to 18 cents, great strides can be made in treating schistosomiasis.

Studies of those treated show that within six months of receiving a dose of praziquantel, up to 90 percent of the damage due to the schistosomiasis infection can be reversed. In the past, praziquantel has been used successfully to treat millions of people at risk for or infected with schistosomiasis in Brazil, Egypt, and China.

Too late for my patients, but there is hope for other Tanzanian children: August 29^th is the official start of the mass deworming project in the Kilimanjaro Region, the first to occur in a few years. All school age children will receive praziquantel and albendezole (to treat other worms). Only one dose is needed (more is ideal, but only one is required). This will also be paired with a massive immunization campaign.

The Tests

During the last few weeks, KCMC has conducted examinations for residents and medical students. The entire institution seems to revolve around this activity and they conduct it quite seriously. I was one of the external examiners this year, having not been here for long enough to be considered an internal examiner. The chief graduating chief resident had both a written and an oral examination and the third year resident had to defend his dissertation in front of a panel of judges. The graduating medical students had a written final in each major discipline, then oral examinations and practical tests (OSCE's). It was a rough few weeks for them and their joy at finishing was apparent.

Each candidate, both resident and student, was required to present a patient on the ObGyn unit to me and an internal examiner. This exercise truly illustrated the state of affairs for women's health in the region. We had patients with almost every condition that we might associate with a low resource setting. There was one patient with eclampsia and intrauterine fetal death, an all too common occurrence here where access to care is often either delayed or not available at all. Capacity on the unit was at a maximum with up to 2 people in each bed at times. There were a number of women with HIV, most notably one who had AIDS and probably pneumocystis pneumonia at 20 weeks gestation. Her husband was a truck driver who was rarely ever home and had refused to get tested for HIV, probably delaying this patient's diagnosis even further. She suffered for weeks before arriving at KCMC for care and was slowly improving on the unit after initiation of antiretroviral medications. Another woman presented in heart failure , severe anemia, with a hemeglobin level of 3.5 (normal >11) and fever at 28 weeks pregnancy. Her anemia was almost certainly from her poor nutritional status and her acute illness from malaria. She was from a village quite a distance from Moshi. Fortunately, over the last 15 years or so, the incidence of malaria seems to have diminished in this region.

Another patient on the Gynecology ward had persistent leaking of urine after suffering obstructed labor for 2 days almost 3 weeks ago. After laboring for 2 days without access to care, she ultimately was able to reach a district hospital where a cesarean section was performed. Unfortunately, about two weeks after the surgery, she began leaking urine and was diagnosed with a vesicovaginal fistula, a hole between her bladder and vagina from the birth injury. Her baby was alive! A rarity for a woman with obstructed labor who go on to develop a fistula. Over 90% of babies die in childbirth when this happens. She is one of only four women in nearly 500 that I've met with fistula who has a live baby. Insult added to injury for these women.

Two other women lay suffering with end stage gynecologic malignancies, one with ovarian and one with cervical cancer. Cervical cancer screening is almost completely unavailable to the women of Tanzania with the exception of some notable programs such as those being developed by Dr. Oneko and colleagues here at KCMC. Unfortunately, this woman never had this screening test. This 47 year old , had she lived in Durham or nearly any other part of the States, would likely have undergone screening by pap smear and would be cured of dysplasia 5 or more years ago, but now lies in bed with stage 3 cervical cancer waiting to die from obstructive uropathy. The practice of gynecologic oncology here yields few options for women because of limited screening and treatment modalities. Advanced stage cervical cancer is almost never treated because of lack of radiation therapy and ovarian cancer is suboptimally treated because of lack of chemotherapy. It is a rare patient that can afford the trip to Nairobi, S. Africa or India for more advanced treatment.

So, it seemed somewhat surreal walking around the wards testing medical students and residents on patient conditions and resource limitations that are merely theoretical at Duke, but in your face here in Tanzania. The students and residents had a superb command of the theory behind optimal treatment for these conditions, but limited experience with employing this therapy because of the resource limitations. Their frustration with this was apparent, but they have learned to live with it and strive for excellence in spite of it. The effects of poverty are pervasive and have a direct impact on women and their families. As outsiders, we can only hope to have a small role to play in improving these conditions. It will be these medical students and residents that make the difference.

JW

Some Stats about KCMC (Kilimanjaro Christian Medical College):

Located about 6 kilometers north of Moshi town, on the slopes of Mount Kilimanjaro, 3 degrees south of the equator.

KCMC is part of Tumaini University, which is part of the Evangelical Lutheran Church. Mount Kilimanjaro is the highest mountain in Africa.

KCMC began in 1997with an initial MD graduating class of 15. In the last few years, there is a big initiative to increase doctors in Tanzania, and KCMC is helping by increasing enrollment to 100 students per year. In 2006, 44% of the incoming medical school students were female. Students can apply straight out of secondary (high) school. The medical school is a 5 year program in Tanzania. Total tuition and fees for foreign students (per year): $5360.

Antenatal Clinic at KCMC- except for people speaking Swahili, I felt like I could have been back in a Prenatal Clinic at any North Carolina health department. Instead of individual exam rooms, elegantly embroidered curtains separate patient tables. The team of nurses take blood pressures, evaluate patients. If there are any complications, the patients see the physician. The antenatal clinic doubles as a gynecology and postpartum clinic as well. All patients carry their antenatal card with them, which also includes their delivery and postpartum record as well. When patients are seen at KCMC, they also have a KCMC file record as well.

The patient has to travel a bit through the hospital before being seen in the clinic. The hospital hallways are like a maze, somewhat resembling Duke South. Patients first present to the clinic, so the doctor or nurse can sign their appointment card for the day- this allows the patient to go to Medical Records, to pay ~$1 to have their file pulled. Then files are brought to the clinic by the Medical Records attendant. If you have never been seen at the hospital before, it costs ~$4 to get a file created (about a day’s wage for a non-skilled worker). The clinics are walk-in clinics, so that all patients are assured being seen although they may have to wait a few hours. The cost of a normal vaginal delivery is ~$15, compared to a (charitable) private hospital which charges ~$78.

Some things feel just like home. Health insurance has arrived in Tanzania. So far, only government employees are offered health insurance on a regular basis, for a small monthly fee. For any patients with insurance, the health care providers must have diagnostic codes. There is an 18 page book full of diagnostic codes for all sorts of conditions. The front page has the 44 most common conditions- they range from asthma, allergic rhinitis, bronchitis, anemia and rheumatoid arthritis to malaria, shigellosis and hookworm.

SH

The first step

4th August 2008

It has been almost 4 weeks since our arrival here in Moshi to begin the collaboration between Duke and KCMC in women’s reproductive health. The transition has been smooth in many ways and rough in a few. Our housing issues seem the most pressing while two Hitchcock movie-like attacks of fire ants have been the most challenging and somewhat frightening to these US doctors. Many of the projects that seemed simple to achieve from that side of the ocean look more daunting when confronted face-to-face. These realities are balanced by a host of other interesting and worthwhile opportunities that have emerged since arriving. Grant Smith, the Hart Fellow scholar who came with us for the year, has been an invaluable addition to the team. He’s bright, energetic, technically savvy and really a joy to be around. One can see why Harvard Med wanted him there

The first two days here were sunny and warm with Kilimanjaro resplendent in our front window. Since then, the mountain has barely shown itself for the clouds and rain. We understand that the dry season is coming soon. With all the clouds and rain, everyone who has lived here for more than a few months is feeling cold and damp. The climate is actually quite nice; Especially when compared to Durham at this time of year. I spoke to Alice yesterday and she said it was in the high 90’s and humid. I’ll take Tanzania weather any day.

KCMC is situated in a beautiful campus on over 500 acres of land. A huge new medical school building is going up and is planned for opening in October or November. There has been a mandate from the government to continue to increase the number of medical school positions and KCMC is no exception. This mandate has not necessarily been balanced by a commensurate increase in capacity or resources for the institution. A common theme of such mandates….. We’re looking forward to a bright and energetic group of first years coming in at the end of September.

The Department of Community Health at KCMC sends the first and second year medical students to surrounding villages for a day every week or every other week to learn about community health and to develop service based initiatives for these communities. This experience sensitizes the students to the community health care issues that are often unseen in the larger cities and in relatively affluent towns such as Moshi. We are working with this department in the hopes of establishing a longitudinal assessment of supplemental medical student education in women’s reproductive health. After completing medical school, doctors complete a one year rotating internship and then are sent to an area of need as a medical officer for a year. This is usually in a remote location and they are often then only doctor present. They have to take care of everyone and their training is often lacking in the care of women. We hope this will not only sensitize students to the special issues of women’s health in this setting, but also give them some practical tools to use in the care of acute obstetrics and gynecologic emergencies as well as basic family planning, antenatal care etc. We hope to track this group of students as they march through medical school and see how an additional program of education affects their career choice, decision making and knowledge base in women’s health among other issues.

We have the first Advanced Life Support in Obstetrics Course tentatively planned for the first week of November. From what we have seen so far, a systematic approach to managing obstetric emergencies is strongly desired and needed here. We will be working with a colleague from University of Copenhagen who is working in Kagera District, which is in the northwest of Tanzania bordering Lake Victoria.

The laparoscopic equipment generously donated by Stryker surgical sits waiting for shipment in the warehouse in California. We are working on a plan to safely introduce the equipment here without having it rapidly break, get lost or fall in to disuse or create more problems than it solves. The leadership of the hospital, physicians and staff are motivated to see this happen, but a number of complicated things have to happen before we can start.

Dr. Oneko, the head of the department of ObGyn at KCMC, is eager to help develop an East African Maternal Health Network and we hope to have a preliminary meeting on this in January. This would involve women’s health care providers and researchers from Tanzania, Uganda and Kenya. We hope to establish similar data collection tools, clinical protocols and best practices in key areas of women’s reproductive health and learn from each other.

We’re pressing ahead with plans to assist in the cervical cancer screening, prevention and treatment efforts that are already underway and to help develop further capacity, infrastructure and study of the problem of obstetric fistula in Tanzania. We’re trying to refine our focus to avoid getting over-stretched…..perhaps the most difficult task.

Looking forward to seeing you in Moshi!

Jeff and Sumera