Winding Down

 Karibu! 

Wow, it's hard to believe we only have 2 more days at the hospital and start our travel back Friday morning. I really can't sum it up in one or few words. It has been so many things: Ruaha National Park was incredible & luxurious & an experience I wish everyone could have, many of the patients and their prognosis or outcomes have been deeply saddening, the home visit was incredibly eye opening and heartbreaking, the people at Ilula Hospital have been so kind and welcoming, the rainy season in January has been much more enjoyable than winter in MN, I've guilty about the my life and my privilege daily, and I've learned so much more medical and cultural information than I expected to.  

I'm so grateful to have had this opportunity to participate as a PA-S. In future years, I hope so many more students from different disciplines take the chance too. Shoulder to Shoulder is a special group and I'm glad I got to meet so many of them while I was here. Janet and I realized pretty quickly I think that we were meant to take this trip together. John, Solveig, & Cole orientated us to TZ and the hospital so well and made sure all the trains ran on time - I know they felt differently but they managed all the inevitable hiccups that come with a massive endeavor like this very well. Randy, Kari, Comfort, Gary and Ralph were only with us for a short time but I was able to learn so much about the organization, the intent, and the future of this special international relationship (along with some medicine too of course). 

Cole and I started going on walks in the afternoon and discussing a different tropical medicine topic each day. We've covered helminths, TB, HIV, HIV opportunistic infections, diarrheal illnesses, dengue, typhoid, yellow fever, malnutrition, nephrotic syndrome, nephritic syndrome, and G6PD deficiency so far! We've discussed a lot of global health ethics and principles and brainstormed ways to continue to improve the trip also. 

I really hope more students and health professionals can come in future years, I hope to stay involved in Shoulder to Shoulder and come back to Ilula in the future if possible! Some ideas we've discussed that I think are very exciting is growing the didactic portion of the trip especially as much of the hospital work is 8-2pm. Making sure to discuss a tropical medicine topic in the afternoon along with the debrief as we have been has been so great. I was nervous after the first few days about what/if I was learning. Now I would say there's no question how much I've learned just by absorbing everything but it's in our medical personal nature to want measurable and tangible objectives. I personally am interested in global health/public health and want to pursue further learning in those areas. We've all had so many conversations about it and wrestling with what the right approach is and are we doing the work correctly/ethically? I think having more knowledge to facilitate those conversations would be so beneficial and hopefully if/when I come back I could contribute something like that.  Ultimately, if I were to pitch this trip to next year students I'd say this is an elective in Global Health and Tropical Medicine. I don't think I came into this trip with that clear of a perspective or understanding of what that really means so it took me the first week or so to wrap my head around it and view it from that lens as a student. It took me a week to answer the "what am I getting out of this?" question that'd been in the back of my head. 

Lastly, an idea I'd had and would love to bring to fruition in some way over the next 5-10 years is starting a formal scholarship program to the clinicians at Ilula Hospital. Again, we've discussed heavily what our impact is here and there's no question it's been positive. For patients - yes and people of Ilula - yes but I think about Dr. Petro, Happy, and Anna. Shoulder to Shoulder has changed those people's lives forever and they've changed the trajectory of their family and future generations too through education and financial stability. I think investing in education is so important - I mean it's been extremely meaningful in my life so why can't we extend that to more people. 

 It sounds like people have been sponsored previously to pursue further education whether than be clinical officer to medical officer, medical officer to specialist, etc. Opening up the opportunity for the staff or graduates of the school here to apply and be selected could be incredible. Giving 3-5(?) people a year to receive a scholarship for tuition feels like a worthwhile investment. Today, I had 2 clinical officer students ask about the process of being sponsored in the future. I think more people then we know are interested in furthering their education. I'm sure the hoops and red tapes would be numerous but I would advocate and work heavily to establish something like that here in the next several years. It would align too with vision for the hospital to become a referral center. 

Isimila, AFCON, and a reflection

Isimila Stone Age Site

Jaci and I visited the Isimila Stone Age Site on Sunday, 1/21, about a 1.5H drive from Ilula (through Iringa). It was overcast and consisted of a muddy hike, but it was still a great experience. The landscape of Isimila reminds me of the Colorado River Basin, specifically the Badlands, Bryce Canyon, and Theodore Roosevelt National Parks. It consists of red earth/dirt with towering pillars dispersed throughout a maze of deep sandstone coolies and canyons.

The site contains a great deal of Stone Age tools presumably used by Homo erectus. These hominid species preceded Homo sapiens on the evolutionary tree, which was the first known hominid to possess modern human body-size proportions that enabled it to walk and run. Interestingly, it existed about 1.9-1.6 million years ago and probably co-existed with several hominid species, as evidenced by their remains being found together in multiple Eastern Sub-Saharan Africa excavation sites. Homo erectus used campfires/hearths and primitive stone tools like cleavers, hand axes, and spearheads which are littered throughout the Isimila Stone Age Site. I love Stone Age history...

AFCON and Tanzania’s group of death

On 1/21 evening, we watched Tanzania’s gut-wrenching 2nd group stage game of the AFCON (Africa Cup of Nations) tournament with Adilly, one of the physicians at Ilula Lutheran Hospital who has become a close friend of mine. AFCON is the primary men’s international soccer tournament of the African mainland that consists of the best 24 teams in Africa (as determined by qualification from a field of 50-60 countries) – it is played every 2 years. This is the first time in several decades that Tanzania has qualified and they are massive underdogs. The game started well for Tanzania, who were thoroughly dominated in every aspect of their first game against the tournament favorites Morocco. Tanzania scored first, and you could hear the raucous cheers from Ilula homes, buildings, dormitories, and the even the hospital despite it being late in the evening. That said, Tanzania wilted in the second half and had to settle for a draw against the heavily favored Zambia. Hopefully, they can win in the final group stage game on Wednesday night and advance!

Reflection

Reflecting on my prior post, I am encouraged by the progress in Ilula and proud of what shoulder-to-shoulder (STS) has built, supported, and empowered the local population to accomplish. There are undoubtedly shortcomings in Ilula, and I have some frustrations, particularly regarding unfortunate or preventable outcomes (like deaths) in the hospital and the allocation of resources, but I remain optimistic about the future. Ilula has a strong nucleus of providers (physicians and clinical officers); I’ve been encouraged by several conversations about the hospital’s future with Dr. Adilly and Dr Malala, even if the path is unclear. 

I believe the ongoing longitudinal relationship/friendship between STS and Ilula is important and necessary. We can engage in two-way education and provide funding support for infrastructure/buildings and medical education; we have the capacity (and potentially the obligation) to gently identify areas we think could be improved or changed based on our experiences in the US (and vice versa). By regularly supporting learners/travelers from the US, we broaden perspectives about global health and healthcare disparities, increase students’ medical knowledge (particularly in travel medicine, tropical medicine, and hygiene), and nurture relationships between Tanzanians and Minnesotans. I think the annual Ilula Medical Conference supports two-way education, networking, relationship building, and quality improvement on a local and (increasingly) national level. 

A blog post

I have noticed remarkable changes in Tanzania’s medical proficiencies and standard of living since I first came to Ilula 10 years ago as a 3rd-year medical student. Throughout the country, the incidence of tuberculosis and HIV has decreased, maternal mortality has dropped, and access to healthcare and life-saving anti-infective medications has increased. Locally (around Ilula), it seems that more houses provide solid protection from the elements with metal roofing and closed doors and windows, new school buildings are gradually being erected, and I’ve seen more tractors in the fields (as opposed to farmers/families with hoes or the occasional cattle). The Ilula Lutheran Hospital now has X-ray and ultrasound equipment, the assortment and availability of laboratory tests have increased, access to medications has expanded, and the facility was formally upgraded from a Clinic to a Hospital. Notably, the hospital and medical providers seem more focused on (and passionate about) medical education, which I presume is partly related to the now thriving Nursing and Clinical Officer schools comprising 153 students!

A decade ago, when I was on the Ilula wards for the first time, patients were often admitted with infectious symptoms or sequelae of malnutrition and frequently had opportunistic infections related to an underlying diagnosis of HIV and the immunosuppressed state it causes (ie, infections that are very rarely found in persons with a healthy/well-functioning immune system). During this visit, I saw very few people living with HIV (or newly diagnosed with HIV) in the inpatient ward and fewer malnourished children, which speaks to the medical progress being made at Ilula.

Despite the medical advances and updated testing techniques, which could help establish a diagnosis for patients admitted to the hospital or at least narrow the differential, I frequently witness local providers using a syndromic approach to treating patients, often with only the help of very brief histories. This means patients are treated empirically based on a symptom and/or findings on examination (or a constellation of symptoms), generally with a brief and incomplete history, and no formal diagnosis or differential is made (to establish a more appropriate treatment or rule out harmful treatments). For example, I’ve witnessed inappropriate administration of diuretics in a malnourished patient, empirical treatment with antibiotics for most hospitalized patients, and a diagnosis of H. pylori-induced peptic ulcer disease being made in nearly all patients presenting with GI symptoms (a frequent occurrence), just to name a few. Here, a diagnosis of H. pylori-induced peptic ulcer disease means more antibiotics, which is occuring frequently enough that it’s made me think about the evolutionary purpose of this bacterium, the ramifications of potentially eliminating it in the population, and the adverse effects this may have on the gut microbiome of Tanzanian’s and their risk for malnutrition.

Last night, 4 patients died. No diagnoses were made, and those made may have been incorrect (I’d argue they were). At Ilula Lutheran Hospital, the clinical officers serve as the primary outpatient providers in non-specialty clinics and assume overnight care for all hospitalized patients. Clinical officers receive 3 years of medical training after completing secondary school, compared to the 5 years plus a year of internship for physicians. Unfortunately, Ilula Lutheran Hospital is currently short 3-5 physicians, and clinical officers are forced to bear the burden of increased patient loads because of understaffing. I don’t know if understaffing and decreased clinical officer oversight contribute, but it’s crossed my mind. I hope they can recruit or hire more physicians to ease the burden.

Lastly, I have a comment about mental health and substance use in Tanzania - topics that are largely ignored. As evidence of this, I don’t think you have to look any further than the presentation at our recent Ilula Medical Conference. One of the new staff psychiatrists, who originally trained as a dentist but returned to medical school for psychiatry (an interesting dichotomy), gave a psychiatry presentation on “mental health” which emphasized that people/patients need to develop resiliency and people can become depressed or anxious with excessive stress. In the US, the breadth of mental health is huge and rapidly expanding – a presentation like this would be analogous to giving a talk on “medicine”.

Robert "Cole" Pueringer

I know something about Happy, who I feel is integral to ILH. She has borrowed money from the German pediatrician so she can finish school. She has asked individuals for help (like me) but I think the help needs to come either from ILH or some other organiztional benefactor. I don't think STS has an actual scholarship fund that fits for her, but perhaps we can think about how we could help her with loan payback or tuition.
Ken

Laughter, conversation and song

 Each year, we ride a bus to and from Ilula to our medical conference in Iringa--about an hour ride.  Our Minnesota group is always accompanied by a dozen or so folks from Ilula: the management team, clinicians, nurses and social workers.  What always amazes me is the conversation and laughter amongst our Tanzanian colleagues on that ride.  They are chattering, in Swahili, all the way back on the ride from Iringa.  Occasionally they will break out in song.  I actually have never had the opportunity to ride a bus for an hour with my own management team and colleagues back in Minnesota. I would not expect that we would be as theatrical and vivacious in our conversations as our Tanzanian friends our.  If I ever have that opportunity, I think, I too, will suggest we sing.

Randy

A Truly Unique Thursday in Tanzania

 Karibu! 

Yesterday, we went on a home visit with Happy, the social welfare office (social worker) and Dr. Petro (psychiatrist) to see a family living about an hour and a half away from the Ilula Hospital.  We piled in 8 people and then picked up a community health worker along the way into the ambulance. I laid on the gurney...it was definitely an experience to be had! We were on paved roads from about 15 minutes I think. We also got stuck in the mud on the way out there which is pretty par for the course for our group at point! Luckily, our driver, Petro and some local farmers were wonderful and got us out fairly quickly. Of course we took pictures of our newest mishap :) 

Upon arriving in this very remote rural village I think we all were immediately reflective of our privilege and fortune. This family consisted of a grandmother with 4 adult children, her oldest is 51 and experiencing psychosis. About 10 years ago she developed visual hallucinations and starting wandering away from home. They began tying her to a rope to keep her from wandering. Fortunately, she is not violent or verbally abusive it seems. Her second child, married a women who is blind and they have two children. A 4 yr old who also has visual deficits and a 1 yr old who seems healthy and normal vision. The 4 yr old boy, Rahema, was insanely cute and seemed to be able to see large shapes at least as he walked up to each of us as the group was talking and Petro and Happy were assessing. He enjoyed Janet's singing and like any small kid was very interested in my Apple Watch. I took it off so he could check it out himself. He brought it very close to his left eye so we think he has some nearsighted vision. Her other 2 children +/- spouses seemed to be around also. 

Happy had visited twice previously and arranged for them to be brought clothes, bedding and helped improve their housing. I estimate the house was smaller than a US college dorm room just with a thatch roof, walls and dirt floors. It's hard for me to imagine what the situation was before Happy helped them. Thank you to the family for giving us permission to take photos.

Ultimately, they decided to take the women with psychosis and family member and back to Ilula with us and then on to Iringa for two weeks of in-patient psych treatment. Happy has found a school for Rahema to be enrolled in and hopes to get him into ophthalmology. However, she has to raise money for clothes, book materials, etc. first. Then she'll return to their home and bring him to school for assessment. 

As we starting walking back to the ambulance to leave we stopped and found Rahema had been following, he wanted to come with. John tried to take him back but he wouldn't leave so eventually, I picked him up and carried him through the field back to his family. When we got about 5 steps away from handing him off he started to whimper and then cry. It was the saddest little noise and made me shed a few tears too. He needs to be with his family but I would've taken him with in a heartbeat. To know how we live our lives in the US - the housing quality & cleanliness, clean purified water, over abundance of food, access to healthcare, resources available for blind children, paved roads, CVS on every corner, reliable electricity, technology, toys, tv/movies, DisneyWorld, etc, etc, etc. 

Poverty and homelessness is undoubtably a problem in American but I think the lack of systemic support through government infrastructural and public health initiatives is what's truly staggering about their level of poverty. The dirt roads, unclean water, growing your own food to survive, no plumbing or electricity - very simple but important structural things that I think we often take for granted in America. This family is trying to do their best with what they have but how much progress can they ever really make? And now that we've experienced this, what do we do with it? What can we do?

Global health aid at work

Wednesday, Jaci and I visited the CTC, which is the HIV Care and Treatment Center. These clinics are all over TZ/Africa and were initially started by the Clinton Foundation and their reach was expanded by George W Bush under the PEPFAR program (President's Emergency Program for AIDS Relief).

The morning did not have many patients, so I spent time talking with the staff. Adam is the program 'tracker' so his job is to follow up with patients who miss their appointments. 

If Adam can't reach the patient by phone, he can ask the community health worker nearest to their village to reach out to the patient & ask them to come in. Adam also shared that the regional CTCs  communicate regularly via What's App chats. They share data and ideas for improvement. If a patient from their clinic shows up at another clinic, they let Ilula know for tracking and vice versa. 

Once several  patients came in, we filled their prescriptions. I even got to count out the meds like a real pharmacist. 

Next we met with a newly diagnosed patient to observe the intake process. First the patient met with Jeremiah, the clinical officer for clinic, to take a detailed history and provide counseling. The patient was initially teary about this news, but Jeremiah was very reassuring.  Next Adam came to complete  all the required forms to enroll as a CTC patient. The clinic keeps a paper record  and also provides one for the patient to take.  The clinic also has a data entry clerk who enters all the info for tracking and aggregation. 

Jeremiah came back after the forms were done to complete the final tasks. Jaci got to write her prescription and then we filled her first 2 weeks of medication. 

This clinic serves over 3000 patients. They are efficient and provide supportive & compassionate care that is leading to long healthy lives for patients with HIV. I have heard that in previous visits to Ilula almost all the inpatients were HIV positive. Now there are only a few on each ward but they are admitted for other reasons- not HIV. The hospital also reports newly screened patients, and everyday we have been here there have been zero new positive cases. 

If anyone has doubts about the value or impact of USAID/PEPFAR, please let me put them to rest for you. This money saves lives - please tell your congressional representatives to reauthorize so this program can keep going.