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