I started out the week by going with a few nurses on the mobile clinic to do maternal-child health in the surrounding villages. This was one of the most interesting days I have had so far. We started at the early hour of about 9:30 by promptly stopping for breakfast before even leaving the town of Muheza. It is nice that people often go and have breakfast/tea together about an hour into their workdays here. We then traveled about 45 minutes on winding dirt tracks to very remote villages where mothers had gathered. There, we conducted baby weighing (took me right back to my days at the dispensary in Moshi- every mother brings their baby complete with homemade pants with harness attached to hang from the large hanging vegetable-style scale to be weighed). We weighed all the babies, then collected all the health records from the mothers to write in the new weight. I provided an endless source of amusement as I had to read the names of each baby and then listen to the mother tell me the new weight in Swahili. They definitely thought my pronunciations of names were hilarious. The mobile clinic returns to each village once a month, so we were also able to follow-up and administer vaccines.
The most interesting part was the health education that the nurses then delivered to the gathered mothers. At the first village, we had probably over 100 mother-child pairs gathered for the events. The education ranged from family planning to STD prevention, to where to go for help regarding post-childbirth fistula formation (which is a big problem in the remote villages where mothers can’t get to larger healthcare centers when the delivery is not progressing in a timely fashion). The mothers were all very attentive and participatory in the education, and it also seemed to provide a bit of comic relief. Although I could not understand most of what was said in Swahili, the mothers at times would be rolling on the ground laughing- for once not at my expense. I was extremely impressed with the lead nurse, Harriet, who was very attentive to the needs of the mothers and tried her best to provide good standard of care to these women. We provided contraceptives- Depo shots, BCPs, and boxes of condoms. All of the services are free of charge as the Tanzanian government funds healthcare for children under 5, family planning, and antenatal services. Harriet told me that there is still so much need, and they have a hard time providing all the services necessary with such limited staffing. They provide HIV counseling, but currently do not have means to bring HIV testing out to the villages, which they are hoping to do in the future when they have more staff to do so. They also have difficulty with the remote villages because it is hard to maintain the vaccine cold chain (less than 4 hours should pass between when refrigerated vaccine is removed from the fridge to when it is administered). As we had to go to 2 villages today, way more than 4 hours passed, but Harriet said it was still better than nothing (probably true). Overall, an extremely interesting day and I think I will go out with them a few more times in the future.
I have spent the rest of the week on OB/GYN. I am working with an English OB/GYN who has been living and working in Tanzania for the past 10 years, along with her husband and 3 sons. We spend the mornings rounding on the labor and delivery wards, as well as the gynecologic ward. This includes post-partum rounds, antenatal rounds, and checking in on the laboring mothers. The majority of births are done by the midwives, unless something goes wrong and a c-section becomes necessary. Interestingly, most doctors are qualified to perform c-section, so when one is necessary it is done by whoever is staffing the operating room at the time. There are a lot of women with eclampsia here who actually have surprisingly good outcomes (in contrast to what we learn in the US). The majority of women who have bad outcomes are due to sepsis/malaria post-partum. Interestingly, they presumptively treat all pregnant women for malaria in the third trimester due to poor outcomes with malaria in pregnancy.
On the gynecologic side, most patients are admitted for issues related to miscarriage or gynecologic cancer. After rounding, we go do ultrasound as needed, and then clinic. Clinic varies from antenatal clinic, HIV+ mothers clinic, and gynecologic clinic. Every day at 10am, she stops whatever she is doing to go and have coffee with her husband, who works in the microbiology lab. It is nice because these breaks have given me an opportunity to learn more about what it is like to come and live/work in Tanzania. There are definitely a lot of frustrations both with living in general here, as well as with working as a physician in the hospital. It is also a very big commitment and risk. Both of them have had to be on HIV post-exposure prophylaxis due to needle stick injuries at various times during their stay here.
I have been learning a lot about HIV in pregnancy here. It turns out that they try to get everyone with CD4s less than 350 on antiretrovirals (not just when less than 100 like I was previously told). The women continue through pregnancy and also during breastfeeding (and then beyond as they wish). This last part is somewhat controversial since it is known that breastfeeding can pass the virus on to the baby, however formula is prohibitively expensive and given the other benefits of breastfeeding it is difficult to recommend otherwise in a place like Tanzania. There have been studies that suggest that when the mother has a high CD4 count and is on antiretrovirals, there is a greatly decreased chance of passing on the virus through breastfeeding. Conversely, if the mother has a mid-lower CD4, then it is more beneficial to have the baby on prophylaxis while breastfeeding. Either way, it is thought here that the benefits of breastfeeding outweigh the risk and so most mothers continue to do so. The HIV+ mothers clinic is a great place for the antenatal and postpartum mothers to come together to give each other support, and also to see the MD to discuss any problems. I was very impressed with how happy the women were to be at the clinic, and how proactive they were about their health and their now chronic infection. There seems to be much less stigma now than there was years ago when HIV was still an emerging disease. People are open to education and to discussing it, and although those that attend clinic and come to the hospital to deliver are a self-selecting group, even in the community it seems that stigma has decreased.
I also spent some time teaching some of the nursing students on the wards, they were very interested to hear my opinions on some diagnoses, and to learn more about certain conditions. It was very nice to speak with them.
This week, it was my turn to cook for “wazungu” dinner, which is a dinner with the English OB and her family, as well as the elective students (two very nice British med students arrived this week from Oxford). The dinner went off with only a few mishaps- including the power going out as soon as the water that I had been attempting to boil for 30 minutes was just reaching a boil, and just as I was starting to cook the pieces. But after locating a gas burner and a kerosene burner, and carrying the partially boiled water through the hospital using scrubs as oven mitts to continue cooking elsewhere, I managed to get everything underway without further issue.
This weekend we are going to Lushoto, which is a town in the Usambara Mountains, to do some hiking and relaxing at a higher (cooler) elevation. Can’t believe I only have a week left in Tanzania before it is back to reality!
The most interesting part was the health education that the nurses then delivered to the gathered mothers. At the first village, we had probably over 100 mother-child pairs gathered for the events. The education ranged from family planning to STD prevention, to where to go for help regarding post-childbirth fistula formation (which is a big problem in the remote villages where mothers can’t get to larger healthcare centers when the delivery is not progressing in a timely fashion). The mothers were all very attentive and participatory in the education, and it also seemed to provide a bit of comic relief. Although I could not understand most of what was said in Swahili, the mothers at times would be rolling on the ground laughing- for once not at my expense. I was extremely impressed with the lead nurse, Harriet, who was very attentive to the needs of the mothers and tried her best to provide good standard of care to these women. We provided contraceptives- Depo shots, BCPs, and boxes of condoms. All of the services are free of charge as the Tanzanian government funds healthcare for children under 5, family planning, and antenatal services. Harriet told me that there is still so much need, and they have a hard time providing all the services necessary with such limited staffing. They provide HIV counseling, but currently do not have means to bring HIV testing out to the villages, which they are hoping to do in the future when they have more staff to do so. They also have difficulty with the remote villages because it is hard to maintain the vaccine cold chain (less than 4 hours should pass between when refrigerated vaccine is removed from the fridge to when it is administered). As we had to go to 2 villages today, way more than 4 hours passed, but Harriet said it was still better than nothing (probably true). Overall, an extremely interesting day and I think I will go out with them a few more times in the future.
I have spent the rest of the week on OB/GYN. I am working with an English OB/GYN who has been living and working in Tanzania for the past 10 years, along with her husband and 3 sons. We spend the mornings rounding on the labor and delivery wards, as well as the gynecologic ward. This includes post-partum rounds, antenatal rounds, and checking in on the laboring mothers. The majority of births are done by the midwives, unless something goes wrong and a c-section becomes necessary. Interestingly, most doctors are qualified to perform c-section, so when one is necessary it is done by whoever is staffing the operating room at the time. There are a lot of women with eclampsia here who actually have surprisingly good outcomes (in contrast to what we learn in the US). The majority of women who have bad outcomes are due to sepsis/malaria post-partum. Interestingly, they presumptively treat all pregnant women for malaria in the third trimester due to poor outcomes with malaria in pregnancy.
On the gynecologic side, most patients are admitted for issues related to miscarriage or gynecologic cancer. After rounding, we go do ultrasound as needed, and then clinic. Clinic varies from antenatal clinic, HIV+ mothers clinic, and gynecologic clinic. Every day at 10am, she stops whatever she is doing to go and have coffee with her husband, who works in the microbiology lab. It is nice because these breaks have given me an opportunity to learn more about what it is like to come and live/work in Tanzania. There are definitely a lot of frustrations both with living in general here, as well as with working as a physician in the hospital. It is also a very big commitment and risk. Both of them have had to be on HIV post-exposure prophylaxis due to needle stick injuries at various times during their stay here.
I have been learning a lot about HIV in pregnancy here. It turns out that they try to get everyone with CD4s less than 350 on antiretrovirals (not just when less than 100 like I was previously told). The women continue through pregnancy and also during breastfeeding (and then beyond as they wish). This last part is somewhat controversial since it is known that breastfeeding can pass the virus on to the baby, however formula is prohibitively expensive and given the other benefits of breastfeeding it is difficult to recommend otherwise in a place like Tanzania. There have been studies that suggest that when the mother has a high CD4 count and is on antiretrovirals, there is a greatly decreased chance of passing on the virus through breastfeeding. Conversely, if the mother has a mid-lower CD4, then it is more beneficial to have the baby on prophylaxis while breastfeeding. Either way, it is thought here that the benefits of breastfeeding outweigh the risk and so most mothers continue to do so. The HIV+ mothers clinic is a great place for the antenatal and postpartum mothers to come together to give each other support, and also to see the MD to discuss any problems. I was very impressed with how happy the women were to be at the clinic, and how proactive they were about their health and their now chronic infection. There seems to be much less stigma now than there was years ago when HIV was still an emerging disease. People are open to education and to discussing it, and although those that attend clinic and come to the hospital to deliver are a self-selecting group, even in the community it seems that stigma has decreased.
I also spent some time teaching some of the nursing students on the wards, they were very interested to hear my opinions on some diagnoses, and to learn more about certain conditions. It was very nice to speak with them.
This week, it was my turn to cook for “wazungu” dinner, which is a dinner with the English OB and her family, as well as the elective students (two very nice British med students arrived this week from Oxford). The dinner went off with only a few mishaps- including the power going out as soon as the water that I had been attempting to boil for 30 minutes was just reaching a boil, and just as I was starting to cook the pieces. But after locating a gas burner and a kerosene burner, and carrying the partially boiled water through the hospital using scrubs as oven mitts to continue cooking elsewhere, I managed to get everything underway without further issue.
This weekend we are going to Lushoto, which is a town in the Usambara Mountains, to do some hiking and relaxing at a higher (cooler) elevation. Can’t believe I only have a week left in Tanzania before it is back to reality!
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