Last experiences from Machame hospital

Local Time:17:00 Sunday 1^st June 2014 – (Or 11:00 in Swahili notation)

Location: Traffic. Just outside of Dar es Salaam

We are seated on the Dar express, the luxury coach we have been on since 7am this morning, when we boarded it in Moshi. Compared to the other transport we’ve experienced so far this bus is certainly luxurious – Mary and I have seat each and don’t having to squeeze next to Tanzanians. Currently the vehicle is stationary in a colossal traffic jam, amidst fumes and chaos as zillions of people and vehicles compete for space to manoeuvre. Like most of Tanzania (but more so), the road is shared by buses, cars, pick-up trucks and daladalas,  all of which are heaving with passengers and cargo and around which buzz pikipiki (motorbike taxis), bajajis (rickshaws), hand carts, and people selling anything and everything. The majority of the highway code seems to have been lost in the translation but they do at least drive on the left, most of the time. Our vehicle has just been hit by a car, an event which ought to be far more common . It seems that our bus is unharmed but the car has lost its front bumper and its owner seems quite annoyed.

Some Bajajis in Tanzania

The bus journey has been quite an uneventful 10 hours, and it has been nice to watch the world go by out of the window in between snoozes. It was a mostly smooth  ride since the Arusha-Moshi-Dar highway is one of the few paved roads in Tanzania, but punctuated by frequent and unforgiving (but necessary) speed bumps and quite a lot of dirt track and temporary road surfaces, road work crews and road rage. En route I thoroughly enjoyed a complimentary ginger beer.

 So we’re on a completely smooth, motionless, section at the moment and I can record the last bit of medicine for a while – I’ve finished the 4 week elective placement but I’m staying to look around Tanzania and Zanzibar for another few weeks.

The Children’s ward

I haven’t ruled out paediatrics as a future speciality, perhaps because I haven’t studied it at all so far.  Misanthropic though I might be, I find it hard to dislike people who are too young to have done anything wrong. And from an efficiency point of view it seems like a good idea to try hard to cure ill children since arguably you get more bang for your buck than with (mostly elderly) adult patients. To be clear, “bang” is a QALY – quality adjusted life year. And bucks are pounds.

So I was excited to see some paediatric medicine at Machame, despite knowing that here more than ever I wouldn’t understand much of what was going on. Like in UK hospitals, the paediatric ward is a bit nicer than the rest of the hospital – It’s a bit more colourful and there’s a large tingatinga-style animal mural on the wall. The names of the rooms could be improved however: malaria room, pneumonia room, diarrhoea room and isolation room.

The first patient we saw was an extremely cute 2yr old Maasai girl. She was tiny – 8.4kg (18lbs) and very anaemic – her haemoglobin level was 5.7g/dL but she seemed paradoxically active and alert. She had had a cough, problems breathing and a fever so a diagnosis of pneumonia was made, and she improved with antibiotics. There were several other children with similar presentations, organised by room.

The doctor explained how for a lot of these children nutrition is a big factor in their health. Breastfeeding is usually recommended, except for HIV+ mothers due to the risk of vertical transmission. High energy formula milk and foods are available but come at a cost, and parents must provide food for their children whilst in hospital, so doctors try and recommend foods that the mothers are more likely to be able to access at home - for example many Maasai eat almost exclusively cow’s milk, cow's blood or raw flesh. It is clear to the doctors that many children will continue without adequate nutrition and so are more likely to succumb to further infections, so common in Africa - particularly when the drinking water is not the safest.

In the isolation room there was an unfortunate 9 year old girl with quite severe skin lesions. She had previously had a fever and was covered in fluid-filled  vesicles – particularly around the neck and armpits. Initially this was diagnosed as chickenpox but soon the condition progressed, the lesions enlarged and some became filled with pus, and eventually there was extensive ulceration around her mouth. It brought to mind some autoimmune skin conditions I know only from textbooks (bullous pemphigoid and pemphigus vulgaris) but both are much more likely found in adults. The doctors decided to treat it as a severe adverse drug reaction, though there was no history of any medications, on the severe end of the continuum of erythema nodosum– Stevens-Johnson syndrome and Toxic epidermal necrolysis. The name and cause of the condition less important than the outcome: the girls was started on steroids and greatly improved.

For another young patient I offered that the appearance of red spots on the chest might help diagnose typhoid fever. It wasn’t a great suggestion: the doctor pointed at me and snorted, “Perhaps visible on your skin!”

A case from outreach

One Thursday Rhi and Laura went on outreach to another difficult to access village and came back quite distressed about a case they had seen, and I think it’s worth briefly telling their story (not plagiarised - I got their permission).

Near the end of the afternoon the girls saw a particularly nervous-looking 15 year old boy who came with his parents. He was small and weak and complained of problems breathing, a problem that had been affecting him for several years, preventing him from playing football with his friends or functioning normally. It was clearly necessary to examine the boy’s chest but he was extremely reluctant to uncover his torso. After a lot of coaxing the cause of his anxiety became clear – he had a large chest deformity. The centre of the boys chest extruded alarmingly forwards creating a sharp bony prominent sternum – known as pectus carinatum, or pigeon’s chest.

One of the Dutch students auscultated the chest and reported that the lungs sounded normal but the heart sounded abnormal, possibly there was a murmur (myself included, when asked to listen to a heart students will always say “I’m not sure but there might be a murmur”). The clinical officer recommended that the boy should come to the hospital for an ECG and X-ray.

The girls were concerned that the boy might have a significant illness, possibly some congenital heart problem or a severe lung disease. Pectus carinatum can be asymptomatic and idiopathic but the history the boy gave made this case seem more worrying. Further, both of his parents were HIV+ but the boy didn’t know whether he had the virus himself.

The clinical officer then revealed that he thought it unlikely that the boy would come to the hospital, the family were very poor and the journey difficult. The tests at hospital, and any treatment would need to be paid for and it didn’t look like the family would be able to afford anything.  The girls offered to contribute to these expenses but remained concerned as to whether the boy would come to the hospital, or indeed whether this would result in any treatable diagnosis. They spent the night worried about the boy.

Miraculously, the boy did turn up at Machame very early the following morning. Rhi and Laura found him and his family (all wearing their finest clothes) in outpatients after church, and thanks to the girls’ funding it was arranged for him to be seen by Dr Sartori, the hospital director and most senior doctor. Happily, after some more tests the boy was diagnosed with simple asthma and given the necessary inhalers. Supremely common, usually benign, very treatable asthma – a good result indeed.

An example of pectus carinatum. (This patient is not Tanzanian.)

This story doesn’t have any fancy presentations or shocking diagnosis, and that’s why it’s worth telling – representative of so many people’s stories in Tanzania. Its a good example of how individuals, and most especially those who are poor, can be terribly affected by even very simple diagnoses. I don’t think it’s an exaggeration to claim that the concern Laura and Rhi showed, and the (by western standards) smallish amount of financial help they provided, vastly improved the lot of a young Tanzanian boy and his family, an appreciated gesture that won’t quickly be forgotten.

The Miracle of Life

I have seen a few caesarean sections here in Machame, all of which went were quick and clean, and I think relatively painless – all children entered the world problem-free, so I’m a big fan. I’ve also spent a few mornings on the labour ward with mothers pre and post-delivery and where the more normal deliveries occur. I’ve only been present at one previous normal delivery, but was too young to really understand what was going on and I can’t remember much at all. The delivery I saw at Machame was far more memorable, though certainly not quick, nor clean, nor painless.

A growing proportion of women in Tanzania now give birth in hospitals, including at Machame many Maasai - these women make up the majority of the ward. The Maasai travel great distances to be treated at Machame (a hospital of considerable reputation in their communities), and can be easily identified by their shaved heads, stretched ear lobes and missing teeth, or the men by the roadside with colourful cloaks, staff and herd of cattle. The Maasai are perhaps the most archetypal African tribe and are a fascinating people- I should write more about them at some point.

Laura and I were hanging around in the labour ward with a student nurse named Chaz, who was patient enough to explain the stages of labour and delivery to us and answer our questions, since we were both pretty uneducated. There are almost no medical terms in this post since I remain pretty clueless about the subject – I can look forward to learning about obstetrics in my next and final year at Birmingham.

Periodically we would pop into the delivery room with Chaz to check on the currently evolving mum-to-be and hold her hand during contractions. The labour ward itself has a delivery room and two pre-delivery beds where women sometimes give birth too, and there is also a nursery of three beds where women stay with their babies for a short while if required.

As the protagonist edged closer to delivery we were gradually joined by more and more student nurses and a midwife, and one of the doctors floated nearby overseeing the spectacle. People talk of childbirth as a wonderful, beautiful and natural process, though to my mind it was the most terrifying and unnatural event I have ever witnessed. It is truly bizarre to watch a human being’s exit from within another human being, and via a totally ridiculous route and manner. Worse, this young man arrived face up (called occiptoposterior presentation I think), a more difficult route than the usual face down position. As the baby finally emerged mother began to chant “hallelujah” and within a few more seconds there was a tiny boy dangling from a string at the foot of the bed, along with various other less miraculous materials. Cutting the umbilical cord looks barbaric, though apparently painless, and after a brief towel dry the screaming creature was bundled up and onto the mothers abdomen – the WHO’s cutely named “kangaroo mother care” procedure that advocates maximal skin-skin contact. The whole process was initially disgusting but I unexpectedly felt warm as the conclusion approached and finally I was so moved I wept. Well, nearly.

After a while the baby was moved to on the side room neonatal unit which has an incubator and was placed in some shoebox-like cot under a heat lamp where he began to quietly suckle on the blanket he was swaddled in. We watched and cooed for a little while and I named him Simba.

Outreached

Outreach

The girls are shopping, and so I am spending my Saturday afternoon typing in my usual Moshi café (not seen a starbucks yet – no free refills) sunning myself in the garden with a big mug of Kilimanjaro coffee. I’m a big fan of Kilimanjaro-brand anything (water, coffee, beer and any product aimed at dim tourists) since yesterday evening as the sun was setting, for the first time in three weeks, the clouds parted in Machame and we saw the hill from the hospital. It really is an unreasonably big hill and it is hard to believe that the whole of its spectacular bulk has managed to stay hidden from view all this time. I am taking its appearance to be a sign that the rainy season has finally ended and so the next weeks will be all sunshine and happiness.

Anyway, I’d planned to spend this time writing a little about the outreach trip Mary and I went on this Thursday, so here goes. The outreach team consists of a nurse, pharmacist and a clinical officer, and perhaps most essential, a big sturdy 4x4 and sturdier driver. Every Thursday the team visit a different village to run a drop-in clinic, providing some basic medical care to people who find it difficult to travel the long distance to hospital. Dressed in our white coats, which give us an undeserved air of legitimacy and authority, we bundled into the car and were driven down the mountain and some 30km, past a sugar plantation, to a village on the river. Of course the dirt roads were very Tanzanian so it felt like a good deal further. Our arrival at the village was a big event and we were instantly made extremely welcome at the church that we took over for the day – I was shocked to learn that the appearance of a medical team at this village happens less frequently than once a year.

Shortly after arriving we all sat down at a table outside and were unexpectedly served a breakfast of boiled sweet potatoes and sweet tea prepared by some of the local women. Once again we were made to feel tremendously and awkwardly VIP, as the pastor and locals all warmly shook our hands, brought us bottled water and made sure we had enough to eat and drink, despite having very little in the way of common language. After prayers, introductions and more prayers a consulting area was set up in the church and the pharmacist neatly arranged the contents of his box of meds on the table.

Mary and I sat with the clinical officer, Oswald. I can’t remember if I have defined clinical officer yet; they’re a bit like UK junior doctors. COs study clinical medicine(in English) for only three years and are awarded a diploma, but can specialise afterwards, or go on to further training: assistant medical officer is the next level and this allows one to use the Dr title. Machame hospital is also a clinical officer school that trains these enthusiastic students; about 180 over the three years and so they outnumber the patients.

We saw about 30 patients, a small number given the size of the village and infrequency of visits. Like at a GP surgery in the UK most of the patients were women, there were quite a few children and a lot of cases of hypertension (usually well over 200mmHg, I began to think of 160 as a healthy value). Treatment options are a bit simpler since the pharmacist only had a small selection of medications, so for example everyone with high blood pressure was given furosemide and, curiously, diazepam. (Where available in Tanzania first line treatment should be a calcium channel blocker, in line with UK NICE guidelines for black patients). As usual I was embarrassed by my lack of local language, but thanks to Oswald’s kind and comprehensive translations Mary and I were quite involved with the history taking, occasional examination and the formation of management plans. There was of course a complete absence of laboratory tests, so ultimately almost any symptom was treated under the presumptive diagnosis of UTI and/or malaria and/or gastroenteritis, for which the treatment offered consisted of both of the only two antibiotics available and some paracetamol.

After we saw the last patient (a gentleman with cirrhosis of the liver, probably due to viral infection but exacerbated by alcohol) we had a delicious late lunch of rice beef and bananas, another example where we have been genuinely and deeply humbled by the repeated generosity, hospitality and dignity of the people here in Tanzania, who often – as was definitely the case at this village – are very poor indeed, apologies for the sentimental cliché. 

some chump and a box of drugs in a landcruiser

On Mosquitoes

More words than necessary about mosquitoes

I was recently pleased to pick up an English-language issue of the Guardian. I don’t think there is any relation to the UK newspaper as there are a number of differences in style and content – for example the puzzle page includes a join-the-dots and a picture to colour in. Mostly there is news of domestic affairs but there is an international section which included the important story, and large and pixelated picture, of people enjoying the weather at a beach in southern England, which I enviously read from monsoonesque Machame.

The front page story was more immediately relevant to me, reporting on a recent outbreak of Dengue fever in Dar es Salaam, a viral disease (also known as breakbone fever due to characteristic joint and muscle pain) that is mostly found around the equator and is spread by mosquitoes. The species of mosquito that carries the bug is endemic to Tanzania but the virus itself is not, so the outbreak is a fairly new problem for Tanzanians. As of 20^th May there were 400 confirmed cases of the disease in Dar, and 3 deaths.

The majority of infections are mild or asymptomatic, so good odds for the individual but this also means that the disease can spread swiftly and silently from unwitting carriers. The outbreak has caused an uneasy atmosphere about the hospital as there have now been a number of cases reported nearby. Most of the staff have no experience with the virus and so it became the topic of a heated discussion in church on Wednesday – bizarrely I was asked to stand up and report what I knew about the disease to the assembly as if I was some wise foreign visiting professor, rather than a bewildered foreign visiting hindrance. I managed to articulate the basics that I could remember – that the disease usually causes a rash and high fever but in severe cases can cause haemorrhage, shock, and (rarely) death, and that since there is no vaccine or effective anti-viral drug treatment is supportive.

I learnt afterwards that my exceedingly English public speaking accent is nearly incomprehensible for the local people so my platitudes largely went unheard. I did manage to communicate that dengue is not present in England and I that I didn’t know how it is diagnosed in English laboratories. I get the feeling that I did nothing to assuage the worry of the congregation, and actually I merely scaremongered with a notion of an unknown and sometimes fatal disease with neither a simple diagnostic test nor a definitive treatment.  Dengue sharply contrasts with that other, commoner, mosquito-borne scourge that the hospital is so familiar and comfortable with - patients with almost any presentation are often labelled “clinical malaria” and started on anti-malarials. The doctors like diagnosing malaria because they know how to treat it, and the placebo effect is pretty effective too.

So now, in addition to trypanosomiasis from abundant tsetse flies, I have another reason to keep my blood safe from vicious hungry little arthropods; a task that I have never been able to accomplish with any degree of success. I’m a fraction too big for my bunk in the guest house so either my feet stick out of the end of mosquito net or I inadvertently collapse it onto myself with my somnolent kicking. This isn’t the main problem (the net is full of holes anyway), as in the daytime I rarely remember to use sufficient insect repellent and I am apparently oblivious to the presence of mosquitoes even when they are enjoying feeding on me,  I am usually surprised later to discover a large red itchy swelling.  So the combination of my ineptitude and my delicious delicious blood means that I am getting quite a number of bites and good size dose of mosquito saliva; right now I have a fairly large swelling on my left tricep (making me look uncommonly muscular, though in an asymmetrical unnatural and inflamed manner) and a troublesome lesion on my left little finger – it hurts a bit to bend or use so the alert reader will notice that due to the discomfort of typing I have used the letter Q significantly less frekwently than usual. Fittingly, as I write these last words I have been bitten, again.

Aedes aegypti - as stolen from the internet

Cool ways to prevent dengue – memories from an essay I wrote during my undergrad
No vaccine yet, so we need to control the disease vector:  for dengue these are Aedes aegypti mosquitoes.

Obvious/don’t get bit:

-          Wear long sleeves and long trousers (an advantage of wearing a burkha.) Bonus: no sunburn.

-          Use insect repellent (unpleasant, expensive, health risks)

-          Sleep under an insecticide treated net (But mosquitoes still bite in the day)

Common/low tech:

-          Spray urban areas with insecticide, fairly ineffective but makes a government look proactive.

-          Tanzania are fumigating buses to avoid transmission of mosquitoes around the country – but asymptomatic humans can easily travel and spread the disease

-          Drain pools that are mosquito habitat – often impractical

-          Add larvacide to mosquito habitat – might involve poisoning water supplies

Biological control:

-          Introduce fishes that eat mosquito larvae – disruption of ecosystem

-          Introduce bacteria that infect mosquitoes, reducing their lifespan and viral transmissibility

Add more mosquitoes/cool high tech science fiction stuff:

-          Release sterilised male mosquitoes, causing a population crash

-          Release self-destructing mosquitoes, males which carry a lethal gene, causing a population crash

-          Release female-incapacitating male mosquitoes, modified genes when expressed in female offspring cause development without wings, and so these mosquitoes rubbish at living or transmitting disease

-          Add genetically modified virus-resistant mosquitoes to outcompete and replace the existing harmful population

Life and Radiation

Domestic Life as a Machame Elective Student

Pole pole: slowly slowly

This second weekend in Africa has been easy-going, much like the Tanzanian lifestyle. We went to Moshi for dinner last night and this afternoon walked up the hill to Machame gate (1800m) – the starting point for one of the routes up Kilimanjaro. 90 minutes of uphill in the sticky heat provided me with good evidence that my no-protein, no-exercise lifestyle of late is not good for one’s physical fitness; the breathless few hundred metres were extremely difficult. I blame the altitude. I have new respect for my robust sister who made it up to the snow-capped summit (a fair bit higher at nearly 6000m) a few years ago.

Last night the clouds parted briefly and we caught our first glimpse of the summit, from plastic chairs on an extremely African rooftop bar in Moshi; sipping “Kilimanjaro” brand beer, taking lots of pictures of the tiny and barely visible segment of the mountain and generally behaving as foreign and touristy as possible, to the amusement of the locals. Our guest house allegedly boasts spectacular views of the hill but unfortunately in the past fortnight we have only seen spectacular views of clouds (and rain).

The clouds and the rain, and humidity, has made drying clothes nearly impossible. I had found the hours bent over a basin of suds scrubbing my sweaty and muddy clothes quite therapeutic, but ultimately futile since in the many days it takes clothes to dry they acquire a distinctive damp and mouldy fragrance. In a rare stroke of genius I took my wet towel with me on the most recent trip to Moshi (down the mountain where it is always hot and sunny) and it dried within a few hours on the back of my chair in the café’s garden.

Luckily the towel doesn’t need washing so very often since I shower less frequently in Tanzania; grime, dust and sweat all now feel normal, I’m reluctant to wash off my life-saving DEET, and the guest house shower is fairly primitive. The shower head provides a dribble of (beautifully warm) water and is precariously held up in a surgical mask sling by knotted surgical gloves. There is no shower curtain so the bathroom is effectively a wet-room, but this is not a problem since we’ve all flip flops. Often the power at the guest house goes out so showering (and everything else) is done by candlelight, which when coupled with the sound of thundering rain on the roof makes for a near-spiritual experience.

The guest house has a small kitchenette containing a propane fuelled 3-ring stove, oven, fridge, and an ant infestation requiring daily mass execution.  Planning and preparing meals is often the major event of the day. We have a frequently topped up kitty from which to buy groceries, and usually all cook and eat together. Mainly we buy from the local dukas (shops) up the road: potatoes, avocado, tomatoes, onions, carrots, bananas and oranges (inappropriately named as they are green on the outside and yellow inside), and so are living almost entirely vegetarian and keeping relatively healthy. So far we’ve made some fairly palatable and creative meals with these few (organic, locally sourced, earthy, pure etc.) ingredients – none of us are missing meat or western food yet. There is ample opportunity to buy chicken and beef, and sometimes goat, from the butchers, but since the animals themselves often look quite unwell and we’ve no idea how long the meat has been hanging up dripping in the heat none of us have been brave enough, yet.

The X ray department

When I become a proper doctor* I am likely to be, initially at least, the over-anxious sort; petrified of missing some terrible disease half-remembered from a footnote of a textbook or Wikipedia’s list of horrifying diseases and the junior doctors that overlooked them. The kind of F1 that is loathed by all radiology departments, requesting X ray scan after CT scan after MRI for any and all patients with the slightest whiff of an indication for them. Nervous doctors like this view X-ray images as detailed blueprints of the inner human body, capable of revealing any imagined problem but only when made intelligible via their expert translators, the frightening troglodyte consultant radiologists – such as my Dad, whom this post is for. In addition to silent greyscale diagnostic imaging, he also likes soundless black and white foreign films, I’m not sure if this association is cause or effect.

The X-ray department at Machame is similarly overwhelmed by requests, but probably nowhere near as many pointless resource-wasting ones. In a damp and darkened nook there exists a room with a single X-ray machine, controlled by an ancient and Frankenstein series of knobs and dials in the adjacent cranny. Along with a dusty ultrasound machine behind it, these make up the entirety of the X-ray department, guarded by a pleasant smiling and limping radiographer. Machame residents are not at risk of radiation exposure from the CT scanner, since it has been broken and unused for several years.

The X-ray images produced are real tangible physical items, not abstract ideas like in the UK. They require developing in a dark room (darkest room: all the rooms are dark) and dried outside, not merely loaded onto a-PACS system and viewed and manipulated via a computer screen. Mostly there are chest X-rays, often showing startling cardiomegaly (hypertrophy of the heart in heart failure) or TB, or films showing various smashed limbs following road traffic accidents. I’ve mentioned before about the fearlessness of local driving behaviours, extending to rapid, multiple-passenger, helmet- and sense-less motorbike driving through traffic. (Incidentally the local word for motorbike is bordaborda, since they’re used to travel from border to border.)

There have also been a few other notable cases whilst we’ve been here, including ionising, under cover of darkness to avoid the disapproval of some of the staff, both an eagle and a monkey from the farm at the bottom of the hill.

*When, not if, because confidence is a substitute for competence. 

Journeys and Laboratories

Day 11 and 12

Lake manyara
Ngorongoro crater

When it comes to safaris I am no amateur. I’ve seen quite a lot of the Really Wild Show, and I very nearly completed the N64 game Pokemon Snap. Nevertheless, it is impossible to come to Tanzania without experiencing the real thing and we were lucky to be able to tag onto the Germans' journey for a discount cost (Safari means journey in kiswahili.). We were picked up at 6am from the hospital and driven 6 hours to Lake Manyara national park. When the sun set we left the park and stayed the night at a relatively luxurious lodge before exploring the famous Ngorongoro crater the following day. It is still the low season in Tanzania so the wilderness felt especially authentic as there were very few other cars in the park, apparently there can be standstill traffic at other times of the year.

The Tanzanian national parks are a bit like West Midlands safari park, only bigger. The scenery is a bit more jaw-droppingly beautiful too, but the idea of driving around and spotting animals is common to both (though in a 4x4 huge Toyota Landcruiser rather than a medium Nissan micra). The weather at Lake Manyara was very African: blaring sun burned most of the white people in the car, but it was an appreciated change from the clouds at Machame, and worth it (I imagine - I don’t include myself in the white people category) for all the animals we saw. We saw all the magnificent Lion King characters we were promised, but more striking for me was the abundance and diversity of bird life; surprising, fabulous, and alien.

Even without the animals I would recommend the safari for the incredible scenery, and driving around in a big dusty hulk of a 4WD looks like great fun too. Our driver seemed to enjoy it, and upon remembering an appointment he had to return from the park for he transformed into a red-eyed maniac rally-driver, more than tripling the 25km/h park speed limit through the dirt tracks and blind corners. He calmed down (only slightly) after we voiced some quite reasonable safety concerns and drove the 6h back to Machame in a hurried manner that might be considered normal for Tanzania.

Bulls on parade

Lake Manyara

Day 12

The Machame Laboratory

I spent the morning in the hospital laboratory, something I haven’t even done in England. An excellent day because for the first time I may have been of greater than zero use to the hospital, as I did a few clinical skills. Until now I have mostly hovered around, lost in the Swahili.

The laboratory is next door to a small clinic room where patients have basic investigations, most commonly haemoglobin levels, urine dips, and blood glucose, but also malaria tests, stool and urine microscopy and venepuncture. I joined forces with a clinical officer student called Wilson and together we ploughed through the list. I haven’t taken blood for months and was a bit concerned since the equipment for these tests is quite different from the standard NHS kit, but, happily, I didn’t run into any problems. Compared with the UK where everyone in hospital seems to get a full blood count, electrolyte and creatinine checked as often as possible, investigations here are Spartan – these flashy UK tests are extremely rare.

Obviously, as a long-time sufferer of medical student hypochondriasis, I took the chance to test my own blood for malaria (none found). I have surprised myself by not forgetting my anti-malarials yet (‘cause Mary has reminded me every single day), and a good thing too since I have recently become irresistible to the affections of various insects. There aren’t too many mosquitoes - but definitely more than enough - since Machame is at a fair altitude part way up Kilimanjaro, but this morning I found both of my ankles savaged by some other tiny creature – I count over 50 separate itchy lesions. 

Another internet update: the satellite dish at the hospital remains kaput. I'm at the internet cafe now but my laptop seems to be broken, so I'm uploading this from Mary's. I hate technology, but I continue to be alive and well.

Crocs Snails and Nightingales

Days 8 and 9

A first African weekend

Mwenye pupa hadiriki kula tamu
A hasty person misses the sweet things

After a leisurely Sunday breakfast we took a road trip in a taxi, joined by Sarah and Rhi our two new arrivals at the guesthouse – by coincidence also from Birmingham. I was pleased to see that, unlike in every other vehicle I’ve been in so far, this one was equipped with seatbelts. Unfortunately we had more bodies than seats (or belts) and so the safety equipment remained unused. Heading east on the main road we soon turned onto a treacherous and tortuous dirt track that stretched the capabilities of our most definitely “on-road” people carrier. After a slow and bumpy 40 minutes we reached our destination, right on the border with Kenya:

Lake Challa is a beautiful volcanic crater containing inviting clear deep blue water. The area had sweeping views across the African plains and an abundance of wildlife – mostly lizards of all shapes and sizes, but we also spotted praying mantises and a chameleon. The others claim to have seen monkeys too. Unlike at the hospital, it was not pouring with rain and it was a novelty to be too hot (and dry) for the first time.  A lengthy dusty scramble down a hill was required to reach the lakeside where we found a small jetty to sit and eat our packed lunches. These were prepared by the driver and consisted of a variety of deep fried items (samosa-like items, potato-like vegetables, doughnut-like cakes, rice-like sweets) and a banana. What we didn’t eat the fish cheerfully polished off.

The guidebook and hearsay warns against swimming due to crocodiles, but after first investigating some suspicious-looking logs we concluded that the reptiles’ existence is the stuff of legend and so we pressed forward and had a pleasant but cautious dip. We spent the rest of the afternoon blissfully horizontal, reading by the lake.

The walk to the lake

Another animal that might have been encountered is perhaps more dangerous but many times smaller, and not explicitly referenced in my guidebook. Further, its presence (or hopefully absence) gives me a flimsy excuse to write a few lines about something more medical: Schistosomiasis (bhilarzia) is a parasitic disease caused by a number of trematode (worm) species found in freshwater in Africa and elsewhere. The juvenile form enters the human body through the skin where they cause an itchy rash. The parasites mature and migrate to the liver (where they may cause fibrosis) and lungs (causing respiratory disease) where they grow into worms about 2cm long, before moving to the bladder (schistosomiasis is the leading cause of bladder cancer worldwide), urinary system, intestines, and veins (abdominal pain, portal hypertension). 

Schistosomiasis causes diverse symptoms and problems not limited to those in the brackets above. Eggs are released either in the urine or faeces, and these early forms infect and develop in snails to complete the worm life cycle. Over 200 million people are infected with schistosomiasis worldwide; about 20,000 die each year.

Having re-read that last bit swimming suddenly seems reckless and my justification is quite feeble: our driver told us there were no parasites in the water, plus it seemed unlikely given the clarity and apparent purity of the water. And indeed the water was lovely. I’ll pop up to the hospital for a test if I get any symptoms. Effective anti-worm treatment is usually easily available if required.

Day 10

Florence Nightingale day

We found the hospital in a frenzied state this morning; women were hard at work with huge pots over wood stoves, choirs were practising and sound systems were being tested. We found out at church that today, Monday 12^th May, is Florence Nightingale Day, and apparently an extremely big deal in Tanzania.

We had attempted to find some doctors in the morning and were perplexed that they all seemed absent from the hospital, along with most of the nurses. We soon realised that they too were in celebration mode and had all completed their essential tasks double quick early on. Everyone we spoke to was astonished that we weren’t familiar with the Florence Nightingale day and could not believe that we didn’t celebrate it in the UK (“but she was white!”,  “what…not even the nurses?!”). We learnt that Celebrations occur all over Tanzania to honour Florence Nightingale and to recognise the continuing hard work and value of nurses and nursing students. Mr Mushi ensured we were extremely welcome to share in their celebrations – which were spectacular.

Firstly we saw the nurses and nursing students parading around the front entrance of the hospital to an exuberant marching band. Not sure of the correct etiquette we joined the procession as it danced around the courtyard, culminating in church for the second service of the day. By the end of the service each nurse had a candle and the parade continued loudly through the hospital, lighting candles in the wards. Apparently a very skeleton crew of unlucky staff stay behind to look after the patients.

Pink  nursing students at the hospital entrance

The procession then moved to the main hall which had been made up as if for a decadent wedding; decorated with the nurses’ whites and pinks, and also the colours of the Tanzanian flag: green, yellow and black. There were buffet tables of strange food enclosing rows of chairs like a school assembly, with a soundtrack of very African music booming from the speakers.

We sat quietly at the back to listen to whatever came next but Mr Mushi found us and in an, astonishing and kind surprise move, made room for us at the VIP table at the front, facing the rows and rows of nurses, nursing students, and the other attendees behind them. The MC introduced the esteemed guests (with whom we were sharing the top table) and we sheepishly stood to receive applause when it was our turn, waving awkwardly.

There were long energetic Kiswahili speeches and touching gift ceremonies for some of the long serving and respected member of staff. We understood very little of the content but all of the enthusiasm and joyfulness transmitted across the language barrier. At the end of the speeches we were treated to a late lunch of stewed bananas, beef, rice and fruit to complete the strangest and cheeriest day at hospital yet.

On the Human Immunodeficiency Virus

Day 7

The HIV virus (Human Immunodeficiency Virus virus)

I have been interested in infectious disease since I did a few relevant modules in my undergraduate degree, but in the UK the topic is mostly confined to STIs - I’m not a fan. Tropical medicine is limited by geography (caveat something something global warming), the main reason I chose to come to Tanzania (I also span the globe at random). A common, important and interesting infection is HIV and today I had my first real exposure*. Since this is blog is kind of supposed to be about medicine I’ll be including small bits of science and stuff – I won’t be offended if any of my imaginary readers decide to skip it. Sorry if I patronise the imaginary medically-minded readers.

Every Wednesday and Friday patients attend the building next to our guest house for a monthly clinic to follow up their HIV infection, and I sat in on this morning’s. I have obtained a variety of different figures for the HIV prevalence here from different doctors, varying from 5-50%, but the clinic sees about 600 different patients each month. I suppose that there are large numbers of undiagnosed cases as it is asymptomatic in early stages and testing is infrequent (HIV status is not tested before operations), so the true number (locally, nationally and globally) is unknown. Unfortunately many patients at Machame will present late and may have cerebral complications (WHO Stage IV disease) such as toxoplasmosis causing hemiplegia (one-sided paralysis).

The running of the clinic and management of patients is much the same as in the UK and is run according to a sophisticated and extensive pro-forma. Patients have their health checked monthly, and CD4 count every 6 months. As on the NHS, treatment with combination anti-retrovirals is started when the count is below 350 or if the patient is pregnant, and the treatment is changed if it becomes ineffective or there are unmanageable side effects. TB co-infection is common - combination treatment is given as in the UK - and co-trimoxazole is often given as prophylaxis against PCP (PJP) pneumonia (which is either a protozoan or a fungus depending who you ask). The drugs are free for the patients, funded mostly by donations.

The briefest history of HIV
In the early 1980s a new disease spread quickly through gay communities in the USA. The causative agent itself was only identified in 1983 – a virus that spreads through blood-blood contact. Genome analysis indicates that it arose from a similar disease of other primates (SIV) around the Congo River basin, crossing to humans via human consumption of bushmeat: primates such as sooty mangabeys and gorillas.  Of the over 35million (and rising) people infected with HIV, 25% are in Africa, though the continent enjoys only 1% of the wealth. I read some time ago that 95% of new infections are in the developing world, and over half of these do not have access to treatment. I’m still impressed that such a devastating disease can arise, from nowhere, in such a short space of time.  

In the face of these depressing facts I was very pleased to learn that HIV seems to be well managed in Machame, and, (uncharacteristically for me) I think there are reasons to be optimistic. Globally there has been a large scientific response to the challenge; the disease is now quite well understood and education regarding transmission prevention is increasing (circumcision reduces transmission by 65%). There are even whispers of an eventual vaccine. The advent of combination antiretroviral therapy has completely changed the course of the disease such that in the UK patients who are treated for HIV actually have a slightly higher life expectancy than the general population – due to increased contact with health services and increased health awareness. 

Finally a brief internet update: the satellite at the hospital seems to be broken so I'm currently only online at this coffee shop in Moshi. Updates and communications might slow to a crawl. Do not adjust your set.

*i.e. exposure to HIV patients and treatment, not exposure to the virus personally – I think

Neema orphanage

Day 5

Following a recommendation from Mr Mushi (our supervisor) the four of us took the opportunity to visit a local orphanage a short walk down the hill. We arrived during naptime (I was jealous) so were first shown around by a Swedish girl who has been volunteering at the orphanage for the last few months. The place is almost self-sufficient as there is a fairly well stocked farmyard with cows, chickens and pigs, as well as a large area for growing fruit and vegetables.

The orphanage itself is a complex of quite modern buildings, a circle of small houses around a central clearing and playground. The place is funded by various charities, organised by the evangelical Lutheran church of Tanzania, and is run by a small team of hardworking nuns and some volunteers. There are about 40 children in total, divided into three age groups: 0-18months, 18months-3yrs, and 3-5yrs. Many of the mothers had died in childbirth, some from AIDS or road traffic accidents, though many were simply too poor to look after the children.

We spent most of our time in the first house, with the babies. Helpfully they seemed to wake up one by one allowing themselves to be washed and changed in an orderly fashion. I heroically attempted to help change nappies and now claim semi-competence at it, providing there is no requirement for this to be done quickly. I’ve not held many babies before but it’s not as terrifying or difficult as I’d imagined – I didn’t drop even one. The babies were delightful, almost universally quiet and happy, and curious about their strange-looking visitors. And of course, embarrassingly, we took clichéd pictures posing with African children.

I wondered whether we were inadvertently causing harm by swanning in and giving these children such enthusiastic attention before leaving forever- and perhaps spreading infection too. It seemed cruel and thoughtless that we took entertainment in the face of these children’s difficulties and the staff’s toil. Overall I convinced myself that it is good for the children to have a bit more human interaction. I don’t think there are sufficient staff to extend far beyond the feeding and changing duties and with such a workload the babies would often have to be left relatively alone and unstimulated.

A picture of yours truly (centre) and a surprised child (right).

Day 6

After church Mary and I followed Dr Mwanja on his morning rounds, seeing patients admitted the previous day and those who were quite unwell. Taped up on the wall of the female medical ward I found a handwritten list of the commonest diseases at Machame the first five of which are:

1.        Hypertension

2.        Peptic ulcer disease

3.        HIV/AIDS

4.        Gastroenteritis

5.        Malaria

Obviously this would be a more interesting list if I could provide a similar UK list to compare it to. I tried to get one but the internet’s not so quick here so I’ll just completely guess instead. I imagine it might contain a few different things that I’ve seen a lot of in UK hospitals, such as:

MI (Heart attack)/ Cardiovascular disease
Diabetes
COPD (smoking related- lung disease)
Dementia
Cancer (especially gastrointestinal, lung, prostate and breast.)

We saw a lady on ITU (the only room with oxygen cannisters) who had stage IV heart failure; she was extremely breathless at rest. Heart failure comes in at number 7 on the Machame disease list. The doctors think she had had undiagnosed bacterial endocarditis and now had multiple valve disease – her systolic murmur is audible without a stethoscope. Her X-ray showed that her heart took up most of her chest and she had ascites, liver failure, and peripheral oedema. Apparently her condition had improved following high doses of furosemide, a potent diuretic, though her prognosis remained dismal. I was shocked to learn she was only 30 years old.

Today the Imperial girls (Poppy and Sarah) move on to Zambia, we’ll go for a farewell dinner with them in Moshi later this evening. They’re replaced by the return from the coast of some German volunteers, one of which will be my flat-mate for the next three weeks and is currently at the hospital being tested for Machame diseases numbers 4 and 5.

Welcome to Hospital

Day three

Today I went to church for the first time in a while. It certainly won’t be the last: staff and students are expected to attend a morning service daily at 7.45. Unfortunately the message fell on deaf ears since this is conducted entirely in Swahili, but we managed to bow our heads and stand up at the right times. We were introduced to the masses and treated to some truly lovely singing from the choir - we are lucky enough to be able to hear them practise from the guest house too.

We spent the morning in the local clinical officer classroom, consisting of a long and detailed student presentation on a case of peptic ulcer disease and its subsequent discussion. Luckily for us the doctors and students work in English. We toured the hospital making introductions for a little while and then went back to the guestroom for some lunch.

Afterwards we met our supervisor, and made some progress to getting a “working” permit. This involved scribbling my CV on an A5 sheet torn from my notebook (dishearteningly it was not at all difficult to compress to this size), and obtaining passport photos from a man with a digital camera whose friend willing to hold a whitish sheet behind me. The latter task required another daladala trip to Moshi and this time I had to stand, my spine securely kept in this shape (&) by the compressing actions of other bodies from all sides.

After dinner the Imperial girls and I were alerted by Mary’s screams from outside as she became acquainted with a large beetle (between kitkat and penguin bar) whilst talking to her parents. Alarmingly for Mary and her parents on the phone but cruelly amusing for me, this friendly animal flew into her hood and hair before becoming firmly attached to her hoody, eventually requiring kitchen utensils to remove. The situation was resolved peacefully (albeit loudly) with injury to neither man nor beast.

Day 4

A morning in the operating theatre.

This morning I sat in on an internal medicine clinic, mainly seeing patients with hypertension. Apparently an extremely common problem at Machame, and – as in the UK - often overlooked or neglected due it being asymptomatic until complications develop. The doctor used a mercury sphygmomanometer the same as we learnt to use in first year, before they were almost completely replaced by the electric ones due to some theoretical mercury risk. Part way through the clinic the doctor tagged in a different doc and abruptly announced he had to go and perform an emergency caesarean section.

As mentioned before I’ve not covered obstetrics yet and so I was initially quite excited at the prospect. I realised whilst changing into scrubs that I might be about to witness a family’s personal tragedy and my stomach turned over. The lady was given an epidural in theatre, and once the doctor had used the introducing needle to check the absence of sensation in the lower limbs and abdomen the patient was cleaned and draped and the first incision was confidently made. The doctor and nurse worked fluidly without any spoken communication between them and, to my inexperienced eyes at least, operated expertly.

The patient had been in labour since the previous afternoon but the baby was too large to fit through the pelvic outlet. Not knowing much about the procedure I concentrated on noticing some differences from the theatres in the UK, such as the re-using of surgical scrubs, masks, drapes and surgical implements – all of which are single-use in the UK. The anaesthetist had no anaesthetics room, and was content with only a handheld pulse oximeter, GP-style electric blood pressure monitor and a single canister of oxygen. The overall cost to the hospital is quoted at 150,000 shillings, a little less than £60.

Soon after starting the doctor had his hand deep inside the lady;s abdomen and pulled out a unreasonably massive and slimy human baby boy. I declined the offer to help close, remembering to “first do no harm” -especially not catastrophic and absolutely avoidable harm. The baby was over 4kg, which is about the same size as a 5yr old child, and although it was rudely bawling, covered in ectoplasm and had an unnaturally deformed-looking head, it was actually sort of beautiful to behold, really.