Moshi, Tanzania
Kilimanjaro Christian Medical College
3/19/18-4/27/18
My clinical observership experience at Kilimanjaro Christian Medical College in Moshi, Tanzania was incredibly illuminating as to the differences in management, disparities in clinical care and challenges with management of complex disease in a resource limited country. My host mentor, Dr. Neema Minja, was an incredible teacher and clinician who pushed me to become involved in clinical decision making during rounds. I spent 6 weeks on the internal medicine ward at KCMC as a member of the inpatient team. I spent about 3 weeks in the Medical Intensive Care Unit, a 6 bed unit where patients were triaged based on the need for the most acute level of care. I was able to participate in rounds, physical examination, reviewing clinical data, and assessment and plans for patients. I also spent an additional 3 weeks on general inpatient medicine, rounding with Dr. Deng Madut, and an Infectious Disease fellow from Duke who served as an attending on general inpatient medicine. My responsibilities were similar to the MICU.
One of the biggest challenges with clinical care at KCMC was the limited resources available for patients who were critically ill or presenting with complex diseases. Diagnostic tests were often ordered sparingly, and many times were not available due to lab equipment not functioning. Imaging as well was highly limited. While chest x-rays were available and routinely utilized, throughout most of my elective the CT scanner was not functioning and we routinely sent patients to the nearest CT scanner about an hour away in Arusha, even for situations where stat CT scans were necessary. Lastly, medications were often different but in some cases limited secondary to cost. This was evident in the MICU where only one line of vasopressors was available, dopamine, despite the medical team knowing that other lines of vasopressors would be more clinically appropriate.
One of the biggest challenges for the community was that patients would often present with advanced disease, often much later than we would ever see in most of the developed world. Much of this was due to lack of access and cost as a barrier to healthcare. Infectious disease was a common cause of morbidity and mortality. The rate of HIV and Tuberculosis was at least 10% but from a rough calculation I presume about 50% of the admitted medicine patients had been admitted with either of these diseases. Heart failure secondary to hypertension was another common admission. This is unfortunately a preventable and manageable disease, even with limited resources in Tanzania given the availability of low cost blood pressure medications. Part of this is likely from lack of health literacy and access to providers.
My personal interest was management of oncologic disease in a resource limited area. I was fortunate to be present at the grand rounds where the head of oncology, Dr Mkwizu, presented on the challenges associated with managing cancer patients in Tanzania. While many strides had been made, one challenge is the high cost of chemotherapy. Interestingly, a lot of pharmaceutical companies are willing to provide highly subsidized or free chemotherapy to patients in Tanzania, but one limiting factor is often proper workup for these patients, including molecular diagnostics which are not available at KCMC currently. The lack of proper workup limits the ability to prescribe newer chemotherapy agents. Some bureaucratic obstacles also exist for pharmaceutical companies to deliver free chemotherapy as well. Oncology is often seen as a developed world problem, but given some advances in life expectancy this is becoming a more common cause of mortality, along with ischemic heart disease, paralleling what we see in developed countries. The experience here allowed me to realize that there is a huge unmet need for clinicians in developed countries to account of the resource limited management of cancer patients in developing countries and to ensure that adequate attention is given to giving these countries cost effective ways of delivering cancer care. I would hope to be involved later on in my career with spearheading efforts to close the gap between developing and developed countries in work up and therapy for cancer patients.
The experience met and exceeded my learning objectives of comparing management of oncologic disease in Tanzania to the US. One of the most incredible parts of the experience was seeing the variety of diseases that I have never thought I would witness. Another aspect was the collegiate environment that the residents and attending provided for me as a student. I felt involved quite often and contributed to medical care of patients. Some of the obstacles were the language, as patients spoke Swahili, and I could not directly communicate with them. I would often work closely with the resident and ask them questions, or have them translate for me during rounds. Another obstacle was at times there was a fairly large amount of students, which could make discussing cases in depth impractical. Given this, I would try to switch to a team with fewer students to allow for a more interactive experience.
My experience at KCMC and in Tanzania has been an eye opening experience to the disparities in healthcare between developing and developed countries. As my career progresses, I will try to be more involved in global health efforts and with further specialization will hopefully be able to work and collaborate with institutions like KCMC in developing countries to optimize and modernize care for patients. If a future student were interested in an elective at KCMC, I would advise them to seek out residents and attending whom are versed in management in resource equipped countries and to point out the disparities in resource limited countries. Many of the attending and some residents have trained in developed countries and are well versed in differences in management. Internal medicine can be seen as a “slower” department when compared to the emergency department and surgical department, which is often a turn off for students. I would advise working with the MICU team as these patients are critically ill with many acute decisions being made on the fly, along with some incredible teaching. Lastly, building a rapport with the attending and residents will enrich the experience you would have, and would allow for a student to gain incredible insight into management and care of patients.