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