Duke-KCMC Women's Health Partnership

Emergency Obstetrics Training stories

2010-11-18T17:18:00.000-08:00

We've written about the emergency obstetrics training courses before. ALSO (Advanced Life Support in Obstetrics) as it is called, has been one of the most effective, interesting, and sustainable projects we have done in Tanzania.

As all health care providers know, it is one thing to read about uncontrolled bleeding and how to treat it; it is immensely more helpful if you can practice how to treat the bleeding. Especially with your peers, and in a non-threatening situation.

Comparing our ALSO course with the typical emergency obstetrics course offered in Tanzania:

Our ALSO vs. typical course
1. We go to provider’s hospital vs 1. Providers are taken to an outside location
2. Course lasts 2-3 days vs. 2. Course lasts 3 weeks
3. Mostly hands-on, role-playing vs. 3. Mostly lectures, talks
4. Costs ~$130 per provider vs. 4. Costs ~$1200 per provider
5. Each participant can become vs. 5. Usually instructors prearranged
an instructor based on evaluation
6. Evidence-based information vs. 6. Sometimes evidence-based information

It is easier to learn emergency obstetrics training in your own hospital, in just 2-3 days, with your colleagues practicing with you. It is more effective to have instructors who can explain things in English and Swahili. Because of these methods, the ALSO course is a cost-effective training- funded exclusively by individuals (through the Blue Jean Ball funds) and the local Tanzanian hospitals.

In this video, you hear from two KCMC midwives who first were ALSO course participants, and then became instructors. They give examples of how some simple techniques have been able to help them save lives.

Thanks to Dr. Puri, our current global health fellow, we have 4 ALSO courses scheduled in the next month, with more than 100 providers planning to attend.

It has been a while.

2010-10-20T08:05:00.000-07:00

It has been 8 months since our last blog. A few of us were returning to the US, and so we had a lot of projects to complete, teaching to do, research to wrap up, and friends to say goodbye to.
Although Jeff and I are back in America, we plan to continue projects initiated 2 years ago through our colleagues who are still in Moshi, including Ruchi, the Global Health Fellow for the year. Jeff will return to East Africa multiple times this year to continue projects in person.

We also plan to write more. And now that we have access to high speed internet with some computer virus protection, we will finally post some pictures. We will also continue to write about the many challenges, surprises and rewards experienced by our team in Tanzania. We continue to need the support of everyone who has helped us before, through the Blue Jean Ball, and I hope that some of our stories and pictures will be able to show you why.

Below is the introductory part of the video for the Blue Jean Ball fundraiser held February 2010.

Thank You

2010-02-21T07:34:00.000-08:00

To all the wonderful people who volunteered and attended the Blue Jean Ball on Saturday despite the snow and cold: you are amazing. To all the people unable to attend, but who have donated their time, or resources, or money: you are also amazing.

Your efforts affect a wide population that encompasses the Northern Zone of Tanzania. Since KCMC hospital is 1 of only 4 Referral Hospitals for the entire country of 40 million, it officially serves as the hospital of last resort for a population of 15 million people (and also the Kenyan villagers who live right across the border). We have seen patients come from Zanzibar, from Kenya and from the Ugandan border based on the reputation of KCMC hospital. The reality of KCMC is that it has knowledgeable specialists and intensive care possibilities, but frequently lacks the most basic resources such as functioning hemoglobin machines, or blood in the blood bank, or patient gowns for surgery.

None of this is new information, and all of our previous blogs have touched on different aspects of working in low-resource situations. But the one thing that keeps us optimistic is our Duke team's ability to contribute to women's' and newborn's health care.

And on Saturday, 350 people attended and 125 volunteered at (and countless others donated to) an event to raise funds for people that they will never meet.

Because of you:

1. There are women and babies alive in Tanzania who otherwise would not have survived. Due to donations of:
*Ambu bags to resuscitate babies
*Medications to save laboring mothers lives (to treat preeclampsia, postpartum hemorrhage, infections)
*Money for intensive courses on managing emergency obstetrics and newborn resuscitation that have trained more than 255 people in Tanzania so far

2. There are women who have new-found hope in a healthy life. Due to donations: *Allowing doctors (such as Jeff, Masenga, the global health residents) to travel to rural areas to perform fistula surgeries
*Providing women with fistula funds to travel to KCMC and get treated
*Providing women with cancer funds to travel to the only cancer center in Tanzania- located 600 miles away.
*Providing funds for fistula patient's families or nurses to accompany them for support;
* In surgical equipment and supplies to perform more complex surgeries.

3. The doctors and nurses at KCMC and other hospitals in the Kilimanjaro Region have more chances to be empowered. Due to donations of:
*Stipends that allow local midwives and doctors to teach the emergency obstetrics courses to other Tanzanians. Our research has shown that instructors retain their knowledge of emergency obstetrics better.
*Scholarships to allow our local KCMC colleagues to attend important international and national meetings for continuing education as well as disseminating best-practices
*Medical books and supplies that are not available (or are prohibitively expensive) locally, given to colleagues who demonstrate initiative in patient care.

4. Patients have something to smile about. Due to donations of:
*Infant blankets and caps, handmade by people in the US! Sometimes the only gift the baby will have.
*Hundreds of infant caps donated by a North Carolina company, kept the heads warm of so many newborns.
*Money, the poorest patients have received personal items that they could never afford, such as clothes and hygiene items.

Thank you

Sumera

2010-02-11T04:13:00.000-08:00

The baby died after the uterus ruptured. Or maybe the baby died first, setting off the cascade of events leading to the uterine rupture. It's difficult to know the exact story. The patient, E., went to the first hospital after she started having abdominal pain and vaginal bleeding. She wasn’t sure if the abdominal pain was normal labor-related or a worrisome sign, since this was her first baby. She had not felt her baby move for a week.

E. was referred to KCMC for the vaginal bleeding and concerns about placental abruption (but without a referral form we can’t tell if they ever heard fetal heart tones).

What is known is that on admission to KCMC, a lack of fetal heart beats led the staff to do an ultrasound which showed a murky picture with possible placenta previa and placental abruption, but definitely no fetal heart beat. An emergency c-section was called, but first some blood had to be found from the blood bank (because of 2 days of vaginal bleeding). Since a hemoglobin level could take 24 hours for the lab to process, E’s anemia was diagnosed clinically.

During c-section, the chief resident (Zuhura) surprisingly found a ruptured uterus, a dead baby of a healthy size (about 7 pounds) floating in the abdomen along with its placenta, and about 1 liter of blood. She called Jeff to assist, but she handled the emergency well, and E’s vital signs were stabilized. The tough question for Jeff was whether to stitch the uterus back together, or remove the uterus by hysterectomy. E. is a young lady on her 1st pregnancy, and since she could not be asked her thoughts while under general anesthesia, Jeff decided to err on the side of fertility and keep the uterus in place.

E. is doing well today, with her fever resolving and in less pain. By now she knows that her baby has died, although we don’t know when or for what reason.

E’s story is one reason that the residents have instituted a Stillbirth Audit with our help. We plan to collect data on babies who died before admission, during labor or immediately after delivery. We plan to do it within 24 hours of the event, so that the history is fresh in the minds of providers. The entire obstetric staff is behind this initiative, because evaluating the problem is the first step in creating long-lasting and effective interventions to solve the problem.

It is a start.

Sumera

Courage

2010-01-20T12:53:00.000-08:00

Courage
Bravery, guts, nerve, valor, daring, audacity…….
Some people seem to come by courage naturally. Some create a false image of courage for the outside world to see yet suffer greatly on the inside. For some, courage comes involuntarily as it is thrust upon them. In these people we see indomitable spirits from which we all can learn. Take F.N. who has been with us now for a year in the hospital. She was 16 when she became pregnant and delivered her first and only baby that she will ever deliver and it was dead. She had obstructed labor like so many other woman and did not have access to emergency obstetrics care and labored at home for 2 days. She experienced such a horrific injury to the soft tissues of her pelvis from compression of the fetal head that we were unable to even attempt a traditional fistula repair. She was one of a handful that we cannot attempt a repair with a relatively safe, quick vaginal surgery. She had both a vesicovaginal and a rectovaginal fistula and leaked urine and stool constantly. When we saw her on an AMREF (www.amref.org) fistula outreach surgery week, she was malnourished, lethargic, depressed. She had the stench of someone who lays in their own concentrated waste for days with no one to attend to them. Her skin was broken down from the constant wetness and she had deep, painful ulcerations of the labia and buttocks. She had nearly given up hope, abandoned by her family. With Dr. Masenga’s guidance and help from funds from the Blue Jean Ball donations, we transported F.N. to KCMC for care. After countless examinations and tests it was concluded that the Urologists would assume her care because of the complexity of her condition. Despite valiant attempts at diverting the flow of stool and urine and 5 separate surgeries, she had a recurrence of her rectovaginal fistula and because her urine had been diverted in to her colon, she was having stool and urine leaking constantly through the same residual hole in her vagina. One year in the hospital and no hope in site, but she had regained an ever present smile and sense of humor that belied her wretched state.

One last desperate attempt at repair: She arrived in the operating theatre that morning with her usual calm, determined smile, without a hint of anxiety or worry which most of us would have. After so many surgeries, she had very few iv sites and served more as a pin cushion for the anesthetists. Two failed spinal anesthesia attempts added insult to injury. As she lay there after her second spinal attempt and her 7th painful iv start the urine and residual stool from the bowel preparation filled the canvas on which she lay and because of her positioning ran up and around her head. It was disgusting to watch and we hastened to clean her up and apologize for the mess, but she just patiently smiled and reassured us that she was ok as she finally went off to sleep with general anesthesia. What kind of person can endure this level of prolonged suffering and still hold her head high the next day and smile, laugh and walk the corridors of her familiar hospital with her fistula friends? A woman with courage beyond measure and one from whom I will always be grateful for teaching me about humility and equanimity in a way greater than any doctor could ever teach.

Community Health and local healing

2009-12-15T02:46:00.000-08:00

Andy, a graduate student, and I have been working with the Community Health Department at KCMC to help prepare their MD1's (first year medical students) for their longitudinal community health experience. It is a great idea, and I wish my medical school had offered such an experience....years ago.
The MD1's spend 1 Thursday every week in their 1st 2 years of medical school with the Community Health department. Students are placed in groups and paired with villages in the Kilimanjaro region. Initially, they are required to do a community assessment of their village- interviewing the village health leaders, some families, and the health facility- and form recommendations based on their evaluations. Last week, the students presented their findings, and it was a great way to hear about the villages bordering KCMC hospital. Andy and I had each gone with a group to a specific village, so we had a chance to see 1 village closely.
My village was on the road to Kibosho, a rather large village with 12,000 inhabitants, it contained 7 primary schools, 123 local bars and 2 health dispensaries. We went to visit one dispensary. Dispensaries are the most basic level of health facility, and are ubiquitous. Tanzania has a goal of having 1 dispensary every 5 kilometers. This dispensary was privately run by a church, and contained all the essential parts: outpatient area, pharmacy, lab, 6 inpatient/maternity beds and 1 delivery bed. The dispensary was very clean, but it was also very quiet. The entire hour we were there, we only saw 2 patients come through. The villagers say that private dispensaries are not popular because they charge money for medications and services. Usually it is quite minimal- $1 for medications, $5 for a delivery. But this amount is enough to keep people away. We see this at KCMC hospital, where people don't want to pay the $12 fee for a regular delivery and try to stay at Mawenzie hospital (where it is free).
This village also has a local healer, and we were lucky enough to interview him. He practiced from his home, a nice house with a very nicely manicured lawn and driveway. His entire waiting room was filled, and we (the 4 medical students and I) squeezed into his treatment room the size of a closet with 2 babies, 1 child and their anxious mothers. Local healers practice in different ways- some are herbalists, some are spiritualists and a few are quite frightful (see the recent news of albinos afraid for their lives given the high value of their body parts http://www.timesonline.co.uk/tol/news/world/africa/article6901688.ece ). This local healer used to be an engineer until about 15 years ago when he had a vision, literally. He was driving down a lonely road in central Tanzania when he was forced to pull over by a vision in the sky. This vision told him to start healing people in his village, and he continues to get his treatments through visions. As he was talking with us, he was creating suspensions in bottles (he wouldn't tell us what it was) to give to the babies and child. He gave 1 teaspoon to each, and waited 5 minutes. Then he gave the suspensions to the mothers to take home. I admit I was rather conflicted- especially seeing infants given suspensions of unknown yellow liquids, when it sounded like they had some colic. Should I have offered to evaluate the infants with my western medical background and provided my allopathic-based diagnosis and treatment? Who am I to say that my treatment would work better? It definitely would be less mysterious and more standardized. I was surprised to see the mothers willing to pay $1 to the local healer, but not to the dispensary. The healer was not surprised, and he gave us a few stories of people who failed to be healed despite weeks of therapy at the hospital and who were only cured after visiting him. Of course, this conflict of therapies occurs in the U.S. all the time. My patients would tell me about how their Homeopathic doctor, or their Naturalist finally treated their problem after countless visits to my colleagues had failed. I wonder how many of my patients had similar experiences. I assumed that this local healer would be cheaper, or offer services at nights/weekends, or spend a long time with his patients- none of these were true. But he was definitely a popular alternative to the dispensary, or to the long journey to a larger health facility. With so many health facilities lacking basic medicines, laboratory tests, or essential supplies (like blood pressure cuffs or delivery kits), local healers can be an attractive alternative in health care. As we were leaving at the same time as the patients, we heard the mothers thank the "doctor" for his help.

Sumera

Brief trip to Rwanda

2009-12-15T02:41:00.000-08:00

Jeff had a quick visit to Rwanda recently. It's always helpful to get some perspective on suffering. Here is a brief email received from him:

"I made a quick. somewhat last minute trip to Rwanda with Nathan Thielman to help him with a project on emergency obstetrics teaching here. Yesterday, we visited a few hospitals and also had the oportunity to visit two genocide memorials here in Kigali and in a town close by called Nyamata. I had read of many accounts of the Genocide in 1994, and the smaller ones over the past 40 years that lead up to it. It was something else to ride through the beautiful landscapes here and imagine it strewn with corpses. The world sat by and watched as 1 million people were systematically killed. It was sobering to say the least. We are going to Gisenyi today which is on the border with Congo. We are visiting one of the district hospitals there that has a particularly high maternal mortality rate."

More details to come....

Return of the Learners

2009-10-26T00:12:00.000-07:00

This week, the medical students returned to their duties at KCMC. It is an impressive thing to watch so many students fill the campus. Knowing that the medical school opened its doors in 1997 shows how quickly it has become established. Initially, there were only 10 students per class. However, it quickly became apparent that this low number would not help the severe physician shortage in Tanzania. Before KCMC College started its medical school, the only other government sponsored medical school was Muhimbili in Dar es Salaam.

When we arrived last year, it took Jeff and I a few months to finally realize a few things about KCMC hospital and medical school students:

1. The school year starts in October, not in august/September like American medical schools. The reason this matters is that when we arrived in July, instead of joining a new group of students, we landed in the middle of final exams for the entire hospital campus (all the schools: medical, assistant medical officer, public health, residency program, nursing, allied health, you name it). It threw us off for a few months. When Tanzanian students want to come to the US, they get thrown off their usual schedule as well, or may lose almost a year waiting to apply to US based residencies.

2. The medical school class size has undergone a massive increase in students due to a government mandate. At KCMC, this has included the creation of a brand new beautiful medical school facility right next to the hospital. What’s needed are instructors to fill the facility. Currently, the attendings (consultants they are called here), or senior level faculty, not only see patients, perform surgeries, oversee residents and teach students on the wards, they also provide lectures on basic science relevant to their specialty for other students. Because there are not enough faculty, the residents have to teach as well. Helps put the teaching issues at American medical schools in perspective.

3. The medical students, who used to number 10 per class year and now average 100 per class year, all have to rotate through KCMC hospital. The hospital has stayed the same size. So now this week, there are 18 new 5^th year med students who have joined our hospital rounds on the OB/GYN floor. Last year’s class had 10 students per rotation, and that already added to the crowd of 10 3^rd year medical students and 10 AMO students every rotation. We all don’t fit into the morning report room, so the latecomers stay in the hallway, hoping to at least hear the report if not see it. Students have to be extra assertive to make sure they are able to get necessary experiences in. Most medical students, right after they graduate, have to be able to perform c-sections in remote regions (usually without supervision) when they serve as Medical officers. I hope these students make the extra effort.....

4. The medical students follow the British system here, so they can start medical school straight after high school and earn their medical degree in 5 years. So most of them have not had any undergraduate experience or real-world health care experience before starting the path towards becoming a physician. Is this a good thing or bad thing? After our past year, I don’t know if undergraduate study is necessary. It is a nice thing for most undergraduates, especially if they are not footing the whole bill. In a country like Tanzania with such a paucity of doctors, with such poverty, it makes more sense to get students through the education system earlier.

5. The government pays for most residents to go through residency, but that is after requiring 1 year of ‘medical officer’ work in rural parts of Tanzania. In fact, similar to the US system until the 1960’s, medical students do not have to do residency, and after their 1 year of ‘medical officer’ work, they can stay on as a medical officer indefinitely. The government salary is even less than what US hospital residency officers make- and amounts to about $400 per month. I once calculated after a particular grueling shift in the hospital as a resident in America that I had earned $1.20 per hour. No matter what minimum wage was at that point, I knew I had earned less. I see the residents here working hard, making even less, and I feel bad now for complaining.

There are differences from what we were used to in the US medical system. But the things that matter most- trying to keep people alive, women delivering safely, newborns healthy- are the same. And that is why we became physicians in the first place.

Sumera

5 Lives

2009-09-06T01:09:00.000-07:00

Rounds on the ward last week:
Wednesday. First patient- routine patient with fibroids and heavy bleeding: plan for hysterectomy. Second patient, gasping for breath. So many people here die gasping for breath. KCMC hospital is the referral hospital for 11 million people, so the hardest, most desperate patient cases end up here. Gasping for breath leads to miserable deaths. Air hunger, dyspnea, shortness of breath, respiratory fatigue.....little relief for them when there is only one ventilator available in the hospital for non-surgical patients, no morphine. She had been admitted that morning at 26 weeks pregnant with shortness of breath. Known HIV positive patient on antiretrovirals, still a very young woman. Oxygen saturation low (56%) pulse high (160). Suspected PCP pneumonia, but no prior xray and no blood work. Lungs sounded horrible. Declined admission in the ICU as there were no beds, at least no beds for an HIV positive person at that time. Quick bedside ultrasound: Twins at 26 weeks, looked normal- surprising that they were moving with such a low maternal oxygen saturation. Perhaps in the last agonizing throws themselves. The patient received oxygen, antibiotics, lasix just in case, steroids. She looked a bit more comfortable with slightly rising oxygen levels. On to the rest of the patients and plan to check on her in 10 min. The next room, second patient collapses and is not breathing. Pulse 50's . Pupils fixed. Oxygen level 65%. Blood pressure normal. Her neighbor tells us she had a severe headache that morning with a stiff neck and fever. We start A,B,C's (airway, breathing, circulation)......IV.....O2....Bag mask ventilation and a call for anesthesia. Reviewing the record, she had been treated for malaria for the last 10 days at an outside facility. 25 weeks pregnant, single fetus. Live. After a few minutes of bag mask, she breathed a little on her own , but not normally. Anesthesia intubated her and took her to the ICU and she was able to get the one ventilator overnight. As the second patient was being intubated, the first stopped breathing as well and rapidly progressed to pulselessness. A,B,C's, Bag Mask ventilation, CPR, No defibrillator.....15 minutes of CPR, Epinephrine and Atropine, no response, pronounced dead at 11:15.
Back to the ICU: The second patient had normal oxygenation on the ventilator but showed signs of brain death so was extubated and died in the morning. The neurologist said it was likely a subarachnoid hemorrhage.

Justice is the ethical principle that ethical theories should prescribe actions that are fair to those involved. Most commonly in medicine we speak about justice when it comes to allocation of resources. For instance, it is unfair for the rich to have access to life saving drugs or technology in the USA when the poor do not. Or, questioning whether it is ethical to spend 2 million dollars saving one person when 100 die for lack of immunizations that could have been saved with that 2 million dollars. The two cases above are not about our commonly applied notions of justice because justice is most commonly applied and described within the boundaries of a country or a state, sometimes ethnicity or religion or another possibly arbitrary boundary or group identity depending on where you live and what your leaders believe. That is: it is ok to withhold the treatment for X condition for the person in Juarez Mexico, but in El Paso, Texas it would be unthinkable if not illegal even though I could have a conversation with my Mexican neighbor from my back porch in El Paso.
I called out to the residents and nurses for many things when we were handling the above two patients. The one thing I did not call for when these women were dying was a scalpel. I like calling for the scalpel. It usually means some solution to the problem is coming. Typical surgeon. In the US, with these patients, it would have been near the top of the list. Airway, breathing, circulation, scalpel........ Get the babies out fast. For each passing second of cardiac arrest, the baby has a smaller chance of survival. In fact, you even help the woman by removing the baby quickly to facilitate CPR. I didn't call for the scalpel because I knew these babies would not, could not survive here in Moshi and the chances for the mother were dismal either way. There are no ventilators for babies, no NICU, no surfactant, no neonatologist. So, 5 lives, 5 deaths. 2 mothers 3 fetuses- minutes from being babies. Fetuses in Tanzania. Babies in the USA. No overlapping circles of justice.

When crying is a good sign

2009-08-03T04:00:00.000-07:00

I was called to assist with a potential neonatal resuscitation. I didn’t know anything about the patient, her pregnancy history, or her labor issues. I barely had time to put on a white coat and gloves. Peeking into the c-section room from the hallway, I could see the mother with her arms outstretched, and two physicians scrubbed and already starting the surgery. I checked to make sure the ambu bag, oxygen tank, the infant warmer, and the suction tubing were all functional. But I didn’t need to- - the midwife was two steps ahead of me diligently checking over everything. The Labor ward was quite calm, different from my U.S. experience where any potential resuscitation would be surrounded by an atmosphere of nervous tension. Or maybe it has always been just MY nervous tension that I have brought to the labor ward.

When I peek again into the c-section room, another physician has scrubbed in, and I wish I had time to find out the mother’s pregnancy and labor history. Three physicians scrubbed in for a c-section is not a good sign (unless they are teaching new residents). The baby is pulled out, but doesn’t make a sound as it is wrapped in a cloth and rushed to the resuscitation room. We open the cloth to find a limp, wet, slightly blue baby who is not breathing. There are suddenly six hands trying to stimulate, warm, dry, cajole, suction and assess the child. We all try to take a different part of the baby- one person is drying, one person is suctioning, one person is getting the ambu bag ready. I realize that I haven’t looked at the newborn resuscitation algorithm in two months, and in that time I have been travelling, writing grant proposals and scheduling courses and so my algorithm retrieval sections of the brain are sluggish. But with six hands that all know something about resuscitating a baby, I’m hopeful that we can get the baby to cry.

When is a cry more desperately needed than in the first few seconds of life? The three of us (two doctors, one nurse) are all working feverishly to get this baby to cry. In most other settings, we try to dampen a baby’s cry (during vaccine injections, ear checks , late night awakenings, long airplane flights).
After the first seconds of stimulation and assessment , the ambu bag is used, the mask is snug on the baby’s face, and someone is giving positive pressure ventilation. Not me, though. I have taken my hands off the baby, and I notice that she is a girl. A beautiful baby girl, perhaps the mother’s first baby. The other doctor doesn’t know the mother’s history either, as he was called at the last minute also. After just twenty seconds, the baby starts to sputter, fight, and get agitated. And then she belts out a huge cry, a howl of indignation.

Yes!

We three adults finally exhale, smile, and start talking. The midwife takes over completely, as she has years more experience in what the newborn baby needs now. But I stand and coo over the crying baby, happy to hear her. I remember that the c-section room is just across the hall, and perhaps the baby’s mother is also hearing her baby cry for the first time. I think about hearing my children’s first cries, and the relief I felt. It is enough to make me cry as well, and I leave the room quickly.

I still hear the baby crying as I leave the labor ward. What a great sound.

Rallying for Safer Motherhood

2009-06-02T01:00:00.000-07:00

This is the 1st time that I’ve participated in a Safe Motherhood event that featured a clown wearing stilts.
We drove out to Karatu in the Arusha Region more than 3 hours away from Moshi. We went with Mackrine Shao, Regional Coordinator for the White Ribbon Alliance (WRA). The International WRA has gained a lot of positive attention, with celebrity and political endorsements (Sarah Brown, wife of England’s prime minister Gordon Brown, is WRA’s patron, and names associated with WRA events include Melinda Gates, congresspeople and actresses). WRA-Tanzania, I’m proud to say, is quite an energetic national association.
Mrs. Shao is the epitome of a dynamic activist who seems to thrive on the sorts of political and community outreach that takes legwork.
Literally.
One Saturday morning in Karatu we celebrated Safe Motherhood Day. Although Safe Motherhood was celebrated on April 23 in other regions of Tanzania, Mrs. Shao had to postpone this region’s celebration until the District and Regional offices were ready to participate. The initial small group of participants met at the health clinic in high spirits. There were students from a youth band, a dozen NGO volunteers, our family, Mackrine and Kate (a visiting MPH student) who started the approximately 5 km rally through Karatu. By the end, we had about 100 students, 20 townsfolk, the District Medical Officer, the District Assistant Secretary (guest of honor), a theatre group, acrobat troupe, and the man on stilts.
There were a few speeches interspersed between informative entertainment. In a village where maternal and newborn death is a common tragedy, it was interesting to see the topic brought to attention with humor and honesty. Most such events in the U.S., where maternal mortality is rare (11 per 100,000 live births) are filled with powerpoint presentations, earnest lectures, and an aura of sadness.
In Tanzania, the maternal mortality statistics range from 578 deaths per 100,000 live births (Tanzania Demographic and Health Survey) to 950 deaths per 100,000 births (WHO). However, tracking maternal (and newborn) deaths is incredibly difficult- considering that about 53% of women deliver at home, with a traditional birth attendant or a relative, there are many uncounted deaths. If a woman dies on the way to the hospital, her death is not counted by the hospital. The village council is supposed to keep track of deaths and births for each village but it depends on the village, we are told. Frequently, a woman who dies from a postpartum endometritis 2 weeks after delivering is not counted among the maternal deaths.
The KCMC-Duke Women’s Health Collaboration contributed with a demonstration of emergency obstetric techniques. First, Mackrine had to reassure us that we could bring out our anatomically correct demonstration mannequins including a female pelvis and a newborn. We wanted to emphasize to the crowd the importance of delivering with a skilled health worker. Of course, we are just figuring out which health workers are actually skilled in emergency obstetrics- but women still have better odds of getting help with complications if they deliver at a health facility rather than at home. (The argument women give is that the health facilities are so understaffed and undersupplied, they would rather deliver at home knowing that there are no supplies or skilled workers, rather than travel great distances and pay money they can’t afford to deliver in similar circumstances).
To the great delight of the clapping crowd, we safely delivered the baby through the pelvis. Then the women volunteers took the newborn, wrapped in a kanga, and performed a celebratory dance around the stage to the music of the band. The man on stilts disappeared sometime during the presentations, and I don’t’ know if he was from the band, the acrobat troupe or the theatre group. However, he wasn’t needed to keep the crowd interested. After a long morning of speeches, skits, dances, and demonstrations, the rally ended quietly with many thank you’s passed around. By 2 pm, we had packed up our car for the 3 hour drive back to Moshi. Hopefully the rally made an impression on the women watching like it made on us.

I would love to download pictures and video from the day, but I will have to wait until our internet connection is able to handle it.

Sleepless in Moshi

2009-05-26T12:34:00.000-07:00

The strangeness of the last 10 months is difficult at times to fully process or appreciate. Sometimes the writer's block is profound. Sometimes the drivel that comes out on the paper is so bad or comes from a place so bleak that it must be summarily squashed and hence one of the many reasons for the long delay in writing on this blog. After working in low resource settings on many short stints over the last 12 years, I thought there would be minimal difference between the way I internalized these short term experiences and those that one accrues over a longer stretch. I was wrong. The summation of many and varied exposures and the continuous exposure is fundamentally different and should be considered carefully ahead of time by those contemplating it; for there is no taking it back. And our situation is tame by most global health standards. We work in a place where there are only dozens of maternal deaths a year. There are many places that are worse. Losing track of time as we develop this or that program and submit this or that grant. The strain on family and relationships. The vagaries of new professional relationships. Concern over the loss of skills and future potential as a physician in the States. Thoughts of reintegration in to that system and moving on.

Few thoughts and recent patients:

1. Humility: I can remember my first exposure to a large number patients with obstetric fistula in Niger . Leaking of urine from a fistula causes fistula dermatitis. This can look exactly like secondary syphillis (condyloma lata) . After I had cancelled a few patients for surgery because of what appeared to be a rampant outbreak of syphillis amongst our fistula patients, I was promptly educated by an older and wiser colleague who told me what this really was. I sheepishly rescheduled the patients and learned a good lesson. We recently took a young woman to the operating room who was dying of something. We knew not what. She was thin and wasting away. Gaunt, tired. She began speaking of her own death. She had an abdomen full of ascites (fluid) and a large pelvic mass. We chose to operate to make a diagnosis in case this was a treatable type of cancer. We made an incision and on opening the abdomen found what looked like cancer everywhere. Her blood count was too low to try to remove all of this and there was only 1 unit of blood available in the blood bank. She likely would have died on the operating table if we tried to remove the tumor. We took a few biopsies and closed her up thinking there would be no hope for her. I was convinced like never before this was some terrible malignancy and hoped at least it would be one that could be treated, because every day she was closer to death. We pleaded for the pathologist (who already has a backlog of 6 months of cases to read) to give us an answer quickly. In 4 days (a miracle) we had our answer. It was Tuberculosis. We were all elated and once again I was humbled by the variety of ways a patient can manifest a disease and my limited exposures in the past. We began treatment and just three weeks later she was on her way home looking 100% better.
2. One of our patients we brought from Berega (see prior blog) is still here at KCMC. She has a rectovaginal fistula and underwent a loop colostomy to divert the flow of feces. She also has such a small bladder after her prior bladder fistula repair that she leaks constantly anyway. She needs surgery that cannot be done here for lack of a few instruments and expertise. She leaks stool now on to her abdomen through the colostomy instead of between her legs. Perhaps the lesser of two evils for her. There is no supply of ostomy bags, so she wraps a kanga around her to compress the stool and hide its odor for a while and then changes it a few times/day. Noone will take her at this point and we've been asking friends and colleagues to come with the appropriate expertise to help. She may be like that forever.
3. We have at least 4 women on the service dying of cervical cancer. A terrible way to go with bleeding and foul smelling necrotic tissue coming from the vagina. Intractable pain from metastases to the bone. No morphine to ease the pain.
4. 3 recent patients with choriocarcinoma which is nearly 100% curable, but we don't have access to the chemotherapy drugs they need. sent a few to Dar Es Salaam recently to the cancer hospital. Have to decide at some point how much is it worth spending to try to save the life of an individual woman in her prime. Is it $200, $300, $500, $10,000? If we spend $2000 in Blue Jean Ball funds on one woman do we deprive 10 women in the future of some local life saving therapy that we can't afford at that time.
5. 16 year old came in two nights ago at 32 weeks pregnancy with a intrauterine demise (stillbirth) and seizures. She had been treated for days at an outside facility and presented too late to do anything. She passes away yesterday morning. She was an orphan herself and no relative or friend was with her at any point in her labor or death.

Many more interesting and devastating stories, but time for bed.
Our team is going to a sugar plantation tomorrow (employs 10,000 people) to teach the ALSO emergency obstetrics course at their hospital.
A recent article by
Denise Grady at the New York Times
http://www.nytimes.com/2009/05/24/health/24birth.html?_r=1&em

After a Devastating Birth Injury, Hope

2009-02-27T23:11:00.000-08:00

This is the title of a New York Times article this week. You can read the full article at:
http://www.nytimes.com/2009/02/24/health/24hospital.html

Denise Grady, a New York Times reporter, accompanied Jeff, Brandi (our wonderful Global Health OBGYN fellow) and Dr. Masenga (OBGYN physician at KCMC and expert fistula surgeon) to Dodoma in central Tanzania. They held an obstetric fistula surgery training camp, sponsored by AMREF and helped with funds from the Blue Jean Ball (http://bluejeanball.mc.duke.edu/index.html). Denise Grady's article describes the problem facing girls/women with fistula quite well.

2009-01-10T10:21:00.000-08:00

“Tangu lini?” we ask the boy child. Since when?

He is 16 years old, but because of HIV, and malnutrition and social factors that we could only guess at due to our limited Swahili, he looks barely 10. His body is skinny, and he weighs less than my 8 year old daughter. The bumps on his face are like little pieces of yellow-red gum that’s been chewed up into small varied globs and stuck there in haphazard fashion. How long have the bumps been there? For 10 months. Looking through his medical chart, we only find one other mention of the face lesions (although the undecipherable handwriting of the physicians makes it difficult to know this for sure). Two months ago, the physician referred the boy to dermatology clinic where he was diagnosed with molluscum contagiosum. This link shows a picture of another child with molluscum: http://www.cehjournal.org/extra/53_05_01.html.
The referral note from the dermatologist didn’t include any treatment options, or the boy’s probability of improving or being cured. We ask the boy if the dermatologists said anything to him about the diagnosis, or prognosis but he shakes his head no.

We flip through the child’s medical records to see what we can offer him. He is obviously very embarrassed about his face lesions. The only question he asks the nurses is whether we can offer him any cure for his facial disfigurement. He doesn’t ask us, the doctors, directly. He only nods respectfully and offers single word responses. He appears shy and modest, and he has no family members with him that we could question. The nurses tell us that he lives in Moshi with his mother, who runs a business and never comes to his clinic appointments. His HIV status was discovered during an admission to the hospital 10 months ago due to sepsis. Actually, his CD4 count has significantly improved, from 350 to 770, in the last 10 months. But this disqualifies him from the only simple treatment for his facial molluscum- antiretroviral (ARV) medications.

Later that morning, we see a 12 year old cachectic boy with HIV, vomiting, and severe ascites (abdominal swelling) with unknown social situation (Are his parents dead or alive? Who are the different people who claim to be his guardians? Has he been given any of his ARV medications since his HIV diagnosis was made 15 months ago?). The next patient is an 8 year old girl living in an orphanage who has had worsening mental status over the last few weeks despite taking her ARV medications, and who can barely stay awake, stand, or control her stools when we visit her. What is causing her to get worse? Who will pay the $80 cost for her CT scan (luckily, one of the doctors)? Once we know the diagnosis, is there anything we can do about it?

So many mysteries, so many unanswered questions. The one certain thing is that prevention is the best cure. Now, in Tanzania, we have the chance to have HIV-free children born to HIV positive mothers thanks to PMTCT (Preventing Mother To Child Transmission) programs. The latest guidelines call for all pregnant to be screened for HIV at their first antenatal clinic visit, no matter what remote part of Tanzania they live in. Those found to be HIV positive are to receive certain ARV medications starting at 28 weeks of pregnancy, with a more intense ARV regimen during labor. If a pregnant woman doesn’t seek care in time, or doesn’t receive this regimen for whatever reason, the newborn baby is to get ARV medications for 28 days. And with this approach, the number of children with HIV related horrible, complicated medical issues will be drastically reduced. It is definitely not an easy task. Most pregnant women in Tanzania are now being screened for HIV during pregnancy, but only a few who qualify are actually receiving guideline-based ARV medications. Either the medications are not available, or the proper combinations aren’t available, or the hospital staff do not know about the changes, or the patient’s condition doesn’t allow for it.

Before PMTCT was initiated, the Ministry of Health in Tanzania estimated that 72,000 babies a year were infected with HIV by through pregnancy, deliver and breastfeeding. That number could be reduced to less than 8,000 by following the latest guidelines. Although the nurses and staff of the HIV clinics and pediatric wards are working hard to improve the lives of children with HIV, the best treatment is prevention.

I don’t know if we will ever be able to clear the 16 year old boy’s face of molluscum. But because of his plight, we will work harder to ensure more pregnant women receive full PMTCT services and medicines so future children are less likely to have to live with such stigma-inducing diseases. I can’t convey such a complex message to the 16 year old, even if I could speak fluent Swahili. I hope the Dermatology clinic has something more to offer him.

Ah.....Berega

2008-12-17T13:07:00.000-08:00

When Dr. Masenga told me we were going to Berega Hospital in Morogoro to do obstetric fistula surgery, I looked at the map and was able to find Morogoro: A decent sized city in central Tanzania. I didn't find Berega, 130 km west of Morogoro and 40 kilometers from the nearest electricity pole. The drive was beautiful, but it also acutely illustrated for us the deadly reality of living in remote settings for women in labour.

During the first day of surgery, we paused between the first and second surgery long enough to clean the operating room when a woman came in with obstructed labour. She had been labouring for two days and had been transported 15 kilometers on the back of a bicycle to arrive at Berega hospital. The medical officer in charge and an assistant did the cesarean delivery and the baby was blue and floppy. No breathing, a heart beat of about 60 beats per minute. Dr. Mkambo, , one of our chief residents from KCMC, Dr. Vasquez and I and rushed to the baby to help resuscitate. 20 minutes of Bag mask ventilation, chest compressions and a dose of epinephrine later the baby was pink and crying, a little. Mother was fine. This is what we call a near miss for both mother and baby. Two hours later the baby would have been dead and the mother potentially with greater injury. It was great to see Mkambo, just recently trained in NRP and ALSO, seize the opportunity to do what he knew he could to save the baby.

There are countless women who fall on the other side of that "near miss" line.........Waited for too long to decide to come to the hospital. Family could not afford her to go to the hospital. There was no transportation and it was rainy season and the only bicycle in the village could not make it with a pregnant woman in labour on the back. They reached the hospital, but there was no surgeon there to attend to her or she could not pay for her care and was turned away to another facility 50 kilometers away. She arrived on time to the hospital, but waited in labour for 3 days there before anyone attended to her. These are the stories fistula patients tell.

Berega was beautiful. Mud huts, brick homes, beautiful, friendly people with a connection to the land and themselves. Women collected water from holes they dug in a dried up wash a couple of kilometers from town. Women with babies on their backs who survived intact from their deliveries. It was a good trip.

Update

2008-12-03T23:39:00.000-08:00

We've been busy lately and the internet access has been sufficiently unreliable as to discourage an attempt at a long posting. We've accomplished a lot over the last month, especially with emergency obstetrics and neonatal resuscitation teaching. Drs. Mary Hartman and Peter Michelson as well as Janet Fields, nurse midwife, joined us from Nov 3-12 to teach neonatal resuscitation and emergency obstetrics to all of the obstetric providers at KCMC hospital. We have seen the direct impact of this teaching on the lives of women and babies here. One example: We were called a few days ago by one of the residents to an emergency: a woman with antepartum hemorrhage. She had a placenta previa (the placenta is covering the opening of the womb) and had bled profusely at home. We arrived on the scene and the nurses and resident had placed two large bore IV's with fluids running wide open, the patient was in trendelenburg position (head lower than feet, to optimize blood pressure), the operating theatre and blood were being prepared, vitals were being monitored and there was a distinct sense of personal and professional satisfaction amongst her providers that she was receiving the best care possible. Her baby did not make it, but she did. The loss of fetal and neonatal life here is tragically common.

Brandi has prepared emergency kits for the labor ward to deal with postpartum hemorrhage and eclamptic seizures and these are present and available in the ward and have been well received by all of the staff. We have set up refresher courses for all of the providers and plan to assess the level of knowledge and skills retained in this methodology.

We are travelling to Morogoro this weekend for a week long fistula treatment and training camp at Berega hospital and have a similar trip planned to Dodoma in January. We are collaborating with AMREF (http://www.amref.org/) and CCBRT (http://www.ccbrt.or.tz/) with these efforts as well as expanding fistula services at KCMC.

With the help of Vera Mushi, we have identified and travelled to 4 outlying centers to help establish global health rotations for the PA students from Duke. KCMC is a wonderful place to learn medicine, but has many learners and cannot accomodate too many more.

Brandi and Dr. Oneko are meeting with Merck Pharm this evening to discuss potential studies in Cervical Cancer and HPV here in the future. A promising lead.

Looking forward to hearing from you here in Moshi!

JW

Jiggers

2008-11-03T22:02:00.001-08:00

KCMC is never quiet. The bench outside of Labor and Delivery Triage always has family members waiting. The Casualty (the hospital's emergency room) waiting room chairs are frequently overflowing. Very similar to Duke Medical Center’s constant flow of human traffic, but without the traffic lights.

In this context of compelling medical need, I was waylaid by my toe. My fourth digit, in fact. The one that I forget exists. One morning I awoke with a throbbing pain in my distal toe, and seeing a black spot, presumed that I had a splinter. A day later, Jeff develops what we think is a wart on the bottom of his small toe. (Pictured here.) Coincidence? Not if it is a Jigger infestation, according to our resident Jigger expert and Dermatologist neighbor Richard. He took one look at my toe, having never made this diagnosis previously in Wales (which is NOT England, we were corrected), and informed me that I had a living parasite actively producing eggs under my toenail. My children run around without shoes all the time, despite all my attempts, and I am the one with Tungiasis. (or “more commonly known as the chigoebicho de pie (bug of the foot), jigger, nigua, pico, pigue, and sand flea. Chigoe flea is sometimes confused with chigger or harvest mite.” ….or sometimes confused with a splinter under the toenail. Visit http://www.healthinplainenglish.com/health/infectious_diseases/tungiasis/ for some good pictures. )

No one else we know has gotten Tungiasis while being here- it is quite safe to visit and to live. And given Jeff’s last blog about the state of Women’s Health globally, or the fact that teenagers get liver cirrhosis from Schistosomiasis that could be prevented with once-year treatment, or that last week in clinic there was a 7 year old boy who weighed 22 pounds (due to HIV, poverty, and his mother’s recent death), I realize that my infected toe is an insignificant matter. My brain recognizes this fact, but my gut is churning in disgust. So finally 2 days after the diagnosis is made, the infested sites are incised, drained, and thoroughly hidden in band-aids. I still have a black ring under my toenail though- is it a scar….. or is it a persistent infestation?

Thanks

2008-10-23T12:24:00.000-07:00

Brandi and Scott arrived last week. Brandi Vasquez is, as far as I know, THE first, official Global Health Resident in Obstetrics and Gynecology…..EVER. Thanks are due to the Department of Obstetrics and Gynecology, the Hubert Yeargan Center for Global Health, the Duke Global Health Institute, the Blue Jean Ball Committee (and BJB donors!) and Covidien HealthCare for making our presence and work here possible. They have accepted the challenge to support global women’s health on a level previously uncommon if not unheard of at other institutions. Special thanks also goes out to Stryker Surgical and Cardinal Health for their very generous donations to our work here.

Women’s health has languished in the corner of the Global Health house for too long. The Safe Motherhood Initiative has been labeled an “orphan initiative”. Women’s health care has largely taken a back seat to other pressing issues such as HIV. Very little improvements in maternal healthcare have been realized in sub-Saharan Africa in the last 15 years and we are far from on track to reach Millenium Development Goal number 5 of a 75% reduction in maternal mortality by 2015.

“No Woman Should Die Giving Life”.

A nice little saying that warms the heart, but has done nothing to save the lives of millions of the poorest and most under-represented women on earth.

“Since the human race began, women have delivered for society. It is time now for the world to deliver for women.”
Another little feel-good dittie that has gone nowhere. When will this “time” be that mothers are valued enough to prevent their untimely death at the moment when life seems most precious?

Thanks to the generous donations of many of you, we are planning to hold the first combined Advanced Life Support in Obstetrics and Neonatal Resuscitation Courses in a referral hospital in Tanzania on November 3-12. Improvement in emergency obstetric care is the third of three core health-sector strategies designed to reduce maternal morbidity and mortality. We are all excited about the prospects for disseminating this information and technology locally and regionally. Thanks to all who have seen us through to this point and who continue to support us.

The question of Malaria

2008-10-12T02:59:00.000-07:00

I am pleased to report that Barney survived his experience at the Vets and returned home to us as good as new. The total bill was 250,000 Tanzania Shillings which is about $210 USD. This was for blood work, three electrical stimulation treatments (still not sure what those were for) and 2.5 weeks lodging with food. A good deal, all in all, especially when compared with the $250 my brother-in-law just spent on one visit to the Vets in the states for a check-up and a few shots for his new puppy. This also happens to be the full cost to surgically repair a patient with vesicovaginal fistula in many sub-saharan African countries (see www.endfistula.org and more on this topic later).

We were in Bukoba two weeks ago helping to teach the first ALSO (Advanced Life Support in Obstetrics) Course in Tanzania. The flight across lake Victoria from Mwanza was truly spectacular and surprisingly uneventful given that we were flying in a plane that was older than I am with pilots who were half my age. The course was a success. We trained over 40 people in caring for obstetric emergencies and hopefully generated some interest in the widespread dissemination of this teaching throughout Tanzania. The maternal mortality ratio (number of maternal deaths/100,000 live births) in Tanzania remains high at 500 - 900 depending on who's counting. This compares to about 12 in the US.

Towards the end of our week there, I began to feel sick. Chills, Sweats, a pounding headache, muscle aches and fatigue. I nearly passed out giving a lecture on post-partum hemorrhage. Our kind hosts insisted that I go to the hospital in Bukoba to get evaluated. There was no question in anyone's mind, except for mine, that I had malaria. I had been living in Moshi (where the rate of malaria is felt to be quite low) and had been taking Mefloquine for prophylaxis. That said, there is a widespread propensity to make the diagnosis of malaria for anyone with concerning symptoms. I have seen the same in Niger and suspect that this practice is widespread wherever malaria has been common in the past. I had some blood tests done at the hospital. They showed moderate anemia and possibly an atypical infection, viral or......MALARIA! The smear for malaria was negative. I took the pills for malaria, of course, and over the next few days, slowly began to feel better: A scene that has played itself out countless times in Africa and elsewhere: Treatment for malaria when the diagnosis was almost certainly something else. I returned home to Moshi and, feeling a bit weak still, I had the lab tests repeated at the Duke lab and they were normal. Significantly abnormal labs at the Bukoba hospital were likely wrong, leading to assumptions that were also likely wrong. Laboratory issues that people here deal with all the time. No anemia, no abnormal white blood cell counts.... Probably a viral illness. Something my immune system had never encountered outside of East Africa.

The reasons for overdiagnosis and treatment of malaria are many and complex. People are dedicating their careers to figuring this out. Most providers here have seen dozens if not hundreds of people die from malaria. To be wrong about the diagnosis and withhold treatment leads to disaster. To diagnose and treat malaria when it is actually something else that will resolve on it own is somewhat of a self fulfilling prophecy. Treat for malaria...patient gets better...must have been malaria. It reinforces the practice of treating liberally in the absence of data or with data that is suspect. Fortunately the treatment is fairly benign and most people get better. I have spoken to a number of people here who say that they get malaria many times a year and keep the medications on hand and self treat at the first signs of fever or malaise. Have to wonder what this all is doing to the efficacy of the drugs.

Ear drops

2008-09-26T20:59:00.000-07:00

Our 11 year old is sick again. He has already missed 2 days of school, and it is only the second month since classes started. This time, he started crying and clutching his ears at 9 pm on a Sunday night. Naturally, I was sure this was a delay tactic to avoid getting ready for bed, until I looked in his ears with the otoscope. A bulging ear drum full of pus and blood stared back, one side only slightly better than the other.

Our medicine cabinet here in Moshi is impressive. It was impressive in Durham, but it has reached new heights of prevention. And thanks to a yard sale, all of our items are organized into Tupperware boxes. Since we were to be one of only a handful of faculty doctors on the compound, and not knowing what is available in Tanzania, we came prepared. We have antibiotics, anti-inflammatory, anti-viral medications, steroid creams, antifungal creams, antifungal tablets, tablets in german that were donated to our cabinet and that required a google search to identify.

However, we forgot ear drops. Luckily, there are many pharmacies in Moshi town, and I went to one of the biggest. They seemed to have all sorts of medications, prescription and non-prescription. However, the ear drops are a problem. I go through my list of choices: Auralgan- no. Cipro Otic- no. Cortisporin Otic- no. Let’s look at the generic names to see if anything sounds familiar. I mentally kick myself for not learning the Swahili term for “ear drops” or “antibiotic drops”. I have learned how to say “are you having contractions” “does your head hurt” and “is the baby moving”, which are only useful in a Labor Ward.

Finally, they emerge with a tiny little tube of some ear suspension medication I had never heard of, but it was sealed, and had a Pfizer label and tetracycline and steroid ingredients. I paid 11,500 shillings for those ear drops (about $10), and as I left the pharmacy, I did some mental math. It costs 15,000 shillings (about $13) to have a vaginal delivery at KCMC, and we are told that countless women could never afford to deliver there. I just spent almost that much to buy a 4 ml tube of symptom control for my son.

Barney update: Barney is still at the vet’s office. He is getting his final electrical stimulation, and he will return on Sunday. The vet says he is better- we’ll see what that means.

Return on Investment

2008-09-13T01:56:00.000-07:00

A pervasive challenge in Obstetrics is how best to monitor the fetus to ensure “fetal well being”. The ultimate goal is to end up with a healthy baby after delivery. One can listen with a stethoscope like device, a hand held doppler or with continuous electronic fetal monitoring. One can perform an ultrasound. The ability to do this well is a challenge in both low and high resource settings. In high resource settings, we over utilize fetal monitoring and this results in inconvenience and discomfort for the mother, a higher rate of cesarean deliveries and other unnecessary interventions. I have been tempted on occasion to hurl the fetal monitors from the heliport at Duke. In low resource settings, there is often no fetal monitoring. This is almost always due to resource limitations, training and personnel shortages. This paradoxically results in higher rates of cesarean deliveries because obstetric providers cannot reassure themselves that all is well and the smallest of things can prompt an “emergency cesarean”. In our first two months here, we reviewed at least a dozen fetal or neonatal deaths that might have been prevented with fetal monitoring. The loss of a pregnancy is hard on everyone: the patient, her family, the nurses and the doctors. The staff at KCMC were eager to prevent this from happening again and we had discussed some practical means of doing so on a few occasions. It might seem like an easy solution to simply monitor all women in labor or perform a cesarean delivery on all high risk patients. Not a simple task on a ward where there are two patients to a bed and a single nurse looks after 40 patients.

It is rare in medicine that you see teaching efforts bear fruit immediately. We taught the ObGyn residents how to perform and interpret continuous electronic fetal monitoring on Thursday morning of this week. We encouraged its selective use in only high risk patients because of significant resource limitations. That afternoon, a woman presented on referral from a local district hospital. She had experienced eclamptic seizures and had a dangerously high blood pressure prior to transfer. On arrival, she was quickly stabilized and magnesium sulfate was administered to prevent further seizures. A decision needed to be made about delivery: Attempt to induce her labor and deliver normally or expedite the process with a cesarean delivery. Already deemed a high risk patient, the residents performed what is called a non-stress test on the fetus with the single electronic fetal monitor system on the labor ward. They had never personally performed this test. The fetal heart tracing was ominous: Late decelerations with no variability followed by a few minutes of bradycardia (slow heart beat) A sign that the fetus was in trouble. This was the kind of tracing one might see in a textbook illustrating what a fetus looks like prior to intra-uterine death.

A cesarean delivery was performed. Dr. Tina Oneko from pediatrics was on hand to resuscitate a floppy looking baby. We have since visited this healthy looking child in the nursery. Her name is Grace.

Barney

2008-09-11T10:07:00.001-07:00

We adopted a dog in Moshi. His name is Barney. Barney is a mix of a Rhodesian Ridgeback and a Boxer. He’s gentle and fun and BIG. A good dog to have around the house at night. His original owners just returned home to Australia after a 6 year stay in Moshi. A few days after they left, Barney began to look ill. I thought he might be depressed, missing his real parents. He stopped eating and appeared listless. He usually eats anything and is full of life. The local veterinarian made a house call and after a few injections, I was hoping that Barney would be on the mend. He was not eating his usual rice and dried fish dinners so I made a stop at the store to see if I could get him a special treat to perk him up a bit. Looking through the aisles at the store, I noted a host of options for the discerning pet owner. A small store in Moshi, which clearly caters to the expatriot community, had at least 6 forms of dog food. A single can of food was about $2.25. A two weeks’ size bag of dried food cost about $22.00. The average family of four in Tanzania eats for a week for under $10. In the USA, $33,000,000,000 (billion) is spent annually on pet care products, including $14.2 billion on dog food alone. The GDP of Tanzania was about 49 Billion in 2007. The health expenditure per capita in Tanzania is about $50. I spent more on one veterinarian visit and some pet food than the average Tanzanian spends on health care in a full year.

Barney started to look more ill last night. He was panting and could not stand on his own. We lifted him in to the car and drove him to a German veterinarian who lives 17 kilometers away in Machame. The sun was beginning to set as we left Moshi behind. I had promised myself not to stray far from Moshi at night: No street lights, uneven, unmarked pavement, a host of pedestrians and animals on the shoulder and huge trucks with variable safety features. After a ride part way up the foothills of Kilimanjaro, we arrived at the vet’s home and coaxed Barney from the vehicle. He was able to walk to a small clinic down the hill from the doctor’s home. The lab was well equipped with a microscope, hematology and chemistry analyzers and a decent operating table and lights: The envy of many hospitals and health centers in the region. The doctor was efficient and courteous. Not once did he ask how I would pay. It was assumed that I could pay and that I would pay. I thought of the countless patients in hospitals throughout Africa that night who were deprived of testing and treatment because they could not afford to pay. My newly adopted dog was receiving better care than many if not most human patients can get. Was it right to expect treatment for my dog when my patient could not receive the same? Should I allow Barney to languish ill and go pay the hospital bill for the patient in room 25? Would there be some perverse justice in that? This is not a moral dilemma unique to Africa. The 50 million uninsured people in the US can attest to the difficult decisions surrounding healthcare in the richest country in the world. The relative scale of the moral dilemma in Africa, however, is, simply put: HUGE

Late in the Day

2008-08-29T00:59:00.000-07:00

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

2008-08-26T12:56:00.000-07:00

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

2008-08-16T23:13:00.000-07:00

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.

The first step

2008-08-04T00:14:00.000-07:00

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