Muheza: Week 1

The month of April I am completing a medical elective at Hospitali Teule in Muheza, Tanzania. Muheza is in the northeast part of Tanzania, an hour inland from Tanga (a large costal city). Last Sunday, I was dropped off at the bus station by my friend Ibrah, the B&B owner, and Joe. They put me on the bus and waved goodbye, then were gone. I was the only mzungu (white person) on the bus. The bus ride itself was an experience- we would stop at every little town along the way to pick up more and more people, who crowded into the aisles and stood the entire length of the journey as all the seats had long been taken. At each stop, there would be vendors with cardboard boxes stuffed full of water bottles, snacks etc, and ladies with buckets full of tomatoes on their heads that people would purchase through the windows of the bus. A few hours into the journey, we heard a loud banging noise and the bus broke down. We pulled over to the side of the road and the driver and other bus personnel spent the next hot and sweaty hour fixing it. We finally got back on the road only to stop a little while later at a rest stop for food/bathroom break. I didn’t know how long we had to be off the bus, nor really what was going on, so I stayed put. We finally made it to Muheza after a 7 hour trip (complete with a police raid towards the end). I found my way to the hospital and checked in.

The hospital grounds are very pretty with lots of tall trees surrounding the main hospital buildings. The only problem is the trees are literally covered in 1000’s of fruit bats that you can see and hear hanging from every possible niche in the trees. At night they all fly away, somewhere. The student hostel is on the hospital property and is a very basic but homey set up with 6 individual rooms, a lounge, a kitchen (with its own live-in rat), and some toilets and shower areas. There is no running water, but every day some women come and fill up a lot of buckets of water so we have all mastered the art of bucket/sponge showering. Sometimes you even get a frog in your bucket. It is rustic but quickly became home. It also reminds me somewhat of the cabin in Maine. I am sharing quarters with 2 of my medical school classmates, Cordelie and Kevin, and then last week there were also 2 medical students from the UK (Matt and Alex) who were finishing up their elective. Everyone oriented me to the hostel/hospital/town the first day, and we cooked together.

The next morning, we all went to the morning meeting that is basically a meeting of all doctors, head nurses, and clinical officers (mid-level providers) to go over the hospital census and morbidity & mortality cases. The hospital (run by an Anglican diocese) has a census of 150-200 patients, including adult medicine wards, pediatric wards, OB/GYN ward, and surgical wards. There is a large outpatient center where patients will go for routine outpatient visits and also go to be admitted to the hospital (a crude ED). There is also a palliative care department and center. That day, I went to the pediatric ward rounds. There are 2 pediatric wards at Teule, both full of patients (at least one patient per bed, sometimes up to three sharing along with their mothers). The majority of cases are admitted for a combo diagnosis of “malaria and bacteremia.” Basically, any child with a fever is treated as a malaria case and completes a course of antimalarials even if the blood smear is negative for malaria parasites. When the rounding doctor asked me for my opinion on a child who was presenting with fever, cough, and runny nose with the warning to “remember that common things are common,” to which I replied that it could be a viral upper respiratory infection of some kind, I was quickly corrected that it is most likely malaria. I'm not quite sure about all the diagnoses of bacteremia (there aren’t any diagnostic studies to speak of and definitely no blood cultures), but the majority of the kids get a course of ampicillin/gentamicin as the standard drugs of choice (likely because of cost and availability). Let’s just hope that gent isn’t as damaging to hearing and kidneys in children as we learn in medical school. There are also many seizure cases, cases of umbilical sepsis, and a lot of malnutrition. The most entertaining patients that day had been admitted overnight after having consumed some of their uncle’s local drink of choice, and they were still quite inebriated. Ward rounds are interesting because instead of going bed to bed, the doctor and nurse sit at a table in the middle of the room and each caretaker brings their child/child’s chart up to the table to be reviewed for the day. Luckily, there are no HIPAA laws here because there is no privacy and sometimes the doctors and nurses comment on or chastise the mothers to the rest of the ward. However, all the caretakers and patients are very respectful of the doctor. There aren’t many questions asked.

That evening, we went to town and I learned where all the important spots in town are- the water guy who sells us 6L cartons of water, the banana guy, the bread guy, and where you can find chipsi-mayai (the local street/pub food- basically an omlette with french fries mixed in). The empty 6L bottles of water have come in quite handy around the student hostel, and had been used for making drip showers, buckets, and all other sorts of containers.

The following day was also spent on pediatric wards. I saw two really sick kids, one with severe anemia from malaria and another suffering from epileptic seizures. We ordered a blood transfusion and anti-epileptics. The capacity to diagnose and treat in the hospital includes: xray, hemoglobin level, blood smear for malaria parasite, and HIV test (usually first given to the mother in pediatrics if status is unknown); pediatric treatments include limited antibiotics, antiepileptics, and antimalarials, as well as medications for routine conditions such as asthma etc, IV lactated ringers (a saline solution) and oral rehydration solution.

That night, we took the most full dala-dala (local minibus) I have ever been on the 1 hour drive to Tanga. There were at least 20 people crammed in the back, sitting and standing, as well as 2 babies, some large bags of cement, and cartons of food, and a giant branch of bananas. It was interesting, at least there were no animals on board as well. The students have instituted “Tanga Tuesdays” whereby we go to Tanga every Tuesday and go to one of the small resorts there to use their pool, poolside showers, and internet, and also have a good meal. It was glorious.

The next few days were again spent on pediatric wards, and also in pediatric clinic. I enjoyed peds clinic as I was given a lot of responsibility and saw half of the patient load myself. It was interesting trying to communicate with the mothers in my limited swahili, but a lot of the medical phrases I learned in Moshi a few years ago are proving to be very useful and I am learning more. A lot were return visits for a check up post-hospital stay or for medicine refills, but I even admitted one child who still wasn’t doing well at home after hospital discharge. Sadly, I also learned that the two really sick kids who I had seen the previous day had died before receiving their treatments. The treatments likely would not have saved them, although those deaths would have been completely preventable in a US hospital with a full range of resources.

Overall, it was a busy and eye opening week. I am still getting a feel for the hospital and for our roll as students here, but I am already learning a lot about the challenges of medicine in a tropical, underdeveloped country, even at a fairly well set-up hospital like Teule. I am really looking forward to rotating through the other wards in the coming weeks, as well as doing some outpatient and community health activities. I’ll keep you posted!