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Wednesday, August 7, 2013

How does Tanzania take care of its people?

I just got back from Tanzania, where I supervised seven medical students who were doing a couple of really awesome ultrasound projects in Mwanza, the second largest city in this East African country. Mwanza is right on the shores of Lake Victoria, a huge but relatively shallow body of water which Tanzania shares with Kenya and Uganda. Tanzanians are friendly, and the weather in Mwanza was perfect. We were at the tail end of the rainy season, but saw almost no rain, and the temperature was perfect, in the mid-80s during the day and cooling off at night.

Because of the lake, there are huge numbers of birds, egrets, cormorants, storks, kingfishers, brightly colored starlings, and lots of frogs who became vocal at night. Tourists do not come to Mwanza, probably because there are more jaw-droppingly amazing places nearby, including Mt. Kilimanjaro, the island of Zanzibar and the Serengeti. People speak English and Swahili, but mostly Swahili, which makes getting along a little complex. We had wonderful hosts who helped with the language issues, and we all picked up a working knowledge of Swahili, mainly stuff like "hello" and "thank you" and "your liver is fine."

Our projects involved visiting several hospitals in Mwanza and talking to many health care professionals. I was able to go on ward rounds with some of the doctors we met and wandered around one afternoon in the very large public hospital, Bugando Medical Center, which has a medical school and is loosely affiliated with Cornell. There were many hospitals, of varying sizes and capabilities. There were district health centers which were publicly funded and provided care to outpatients and had wards for patients who were too sick to return home. There were dispensaries, which despite their title, did not just act as pharmacies, but also offered clinic services such as doctor appointments, birth control, prenatal care and HIV monitoring. There were also private hospitals which were a little less crowded than the public ones, a little more cushy and required that the patient pay for their own care completely, except in rare cases such as having health insurance (usually only government employees) or having any of the conditions which the government pays for in full.

Doctor visits were both by appointment and drop-in, and there was 24 hour availability of doctor care, though doctors were pretty scarce on nights and weekends. The big hospital, Bugando, had a cafeteria and would serve food to the patients, but that was a rarity, and generally families were expected to bring the patient food and drinks.

In the private hospital the rooms were semi-private, two beds to a room, one person per bed, with a mosquito net. In the public hospitals the wards were open, with 10 or more beds per room, and no curtains between patients. Some had mosquito nets, some didn't. Usual necessities in U.S. hospitals, things like blood pressure cuffs, oxygen and suction, which are attached to the wall, were absent. Most facilities had the ability to do a chest X-ray, some could do an ultrasound, but usually just for female problems and obstetrics. There were very few CT scanners and no MRI in the city. Basic surgery was available, but more complex issues had to go to the largest city in Tanzania, Dar Es Salaam, which was over an hour away by airplane and 10 hours away by car or bus. The nicest hospital room I saw was a cement-floored two bed room that was about 200 square feet with a window, a door, mosquito net, bedside table, sheets and an ancient plastic covered pillow. It wasn't dirty, but neither was it scrupulously clean. There was no electrical outlet or fan, though the temperature was comfortable.

The physicians I saw interact with patients were mostly polite, but clearly didn't spend much time either in examining the patients or taking a history, and it was rare to find any evidence that full vital signs were taken after the patient was admitted, though abnormal ones, such as blood pressure and temperature, were repeated at least daily. Almost everyone got a blood smear for malaria, a urine test, a stool examination for worms and sometimes an antibody screen for typhoid, which was often false positive. Chemistry testing was only rarely done, and not always available, and blood counts were available but not often used. HIV testing was available, and most hospitals had the ability to test CD4 counts to evaluate patients with known HIV.

Prenatal care is available to patients free of charge, as is birth control. Patients are tested for HIV when they first present for prenatal care and receive peripartum prophylaxis to prevent vertical transmission. Vaccination for measles, mumps, rubella, polio, BCG for tuberculosis, hepatitis B, diptheria, pertussis and tetanus are all available and encouraged. There were always lines of mothers with babies at the health centers we visited, there for vaccination. There is no cost to the patient for care for children under 5, pregnant women, patients over the age of 60 and patients with HIV/AIDS or tuberculosis. Women are required to receive prenatal care and deliver their babies at hospitals, though this is far from universal in practice. Since there is very little access to blood tests or ultrasound, it appears that the primary purpose of prenatal care is to identify patients who are clearly at high risk of birth complications and to treat and prevent the spread of HIV.

Sick patients who presented to a hospital would not be denied care, even if they had no money to pay for it, though if they arrived less than dangerously ill, they would be expected to pay for care if they did not fall into a group for whom care was free. Often, regardless of symptoms, patients were treated for one of the top 10 diagnoses, based on the few lab tests that were done, and sometimes were treated based on the most common diagnosis associated with their primary complaint, without confirming lab tests, imaging or examination findings. The top 10 diagnoses were malaria, typhoid, ascariasis, urinary tract infection, sickle cell disease, pneumonia, pelvic inflammatory disease, HIV, infectious diarrhea and diabetes. I also saw patients who had been identified with hypertension and renal failure (one 90 year old patient), cirrhosis and hepatoma (a young woman who probably had congenital hepatitis B), measles (an unvaccinated baby) and severe iron deficiency anemia. It is interesting that in the fast food stalls they sell little sticks of clay for pregnant ladies to eat. Eating clay (and laundry starch and dirt) is called pica, and is strongly associated with iron deficiency in pregnancy. I do wonder if there may be a significant, underrecognized prevalence of iron deficiency in pregnancy.

Malaria appeared to be the most common diagnosis in the patients who were hospitalized, and also was a pretty common diagnosis in the outpatients. A thick blood smear was examined in most of the patients who presented with any one of a number of vague complaints, including headache, weakness and low grade fevers. If parasites were seen, they were treated with appropriate medications, but many people in Tanzania harbor malaria parasites and are not sick with malaria and probably don't require treatment. I'm not sure if the inpatients getting their intravenous quinine actually were suffering from malaria, though I'm sure at least some of them were.

IV fluids are generally available as are appropriate drugs for HIV, malaria and serious infections. There is very little choice in medications for hypertension and even a patient with lethargy due to extremely high blood sugars did not warrant an insulin drip since there was no accurate way to deliver it. I saw one older woman whose blood pressure was 250/120 who had run out of her medications because they weren't available at the health center due to government shortages. She was sent to a pharmacy with a prescription which she may or may not have been able to afford to fill. HIV medications and some of the expenses for the health care centers which provide both the meds and HIV testing are funded by the United States Agency for International development (USAID.) This organization also helps fund maternal and child health and tuberculosis treatment, which has improved numbers like prevalence of HIV and death rates. USAID also is involved in promoting use of condoms for prevention of HIV, which is unfortunately not terribly effective in Tanzania. Birth control with pills or the intrauterine device (IUD) are enthusiastically accepted, but in the clinics I visited I heard that condoms were not very popular, and outside of clinics were rather expensive. There has been a huge increase in the number of people being tested for HIV, which may decrease spread of the disease, and treatment will also reduce transmission.

Tanzania has the lowest ratio of doctors to patients in the world, which may be due to a large refugee population since it is one of the most stable countries politically in East Africa. In Tanzania a person can be called doctor if he or she has completed any of three different medical education programs. After 3 years of medical education, after the equivalent of high school graduation, a person can become a clinical officer and can provide medical care in a clinic with some supervision. After 3 more years that person can become an assistant medical officer, with more autonomy. The medical degree program is a full 5 years, and includes an internship year. If a person starts with a clinical officer degree, he or she can work as a doctor while finishing a medical degree.

The education being offered to clinical officers appeared to me to be pretty rigorous, including anatomy and physiology as well as practical skills that would be part of the work of a hospital nurse in the U.S. My Pocket World in Figures put out by the Economist magazine says that Tanzania has 145,667 patients for each doctor, but it is unclear if they include clinical officers and assistant medical officers in this count. It has a prevalence of HIV/AIDS of 5.6% in people between the ages of 15 and 49, 12th in the world, but far better than Botswana in which 25% of this population is infected. There is very little smoking and drug abuse is uncommon, though there are alcoholics. There is no concept of drug treatment programs or even mental health care. Pain is treated only with acetaminophen or oral or parenteral nonsteroidal anti-inflammatory drugs. There are no opiate pain medications in the hospitals I visited, even though physicians recognize that these would be merciful in many circumstances.

I am very impressed by the level of basic medical care provided in Tanzania, and people do have a kind of safety net should they become very ill or injured. Many of the big-ticket, costly items of medical care are heavily subsidized by the U.S. which pretty much bypasses the government, assuring ongoing care of high risk individuals even when government budgets get tight. Still, Americans would definitely rank their own health care system far above Tanzania's. Availability of technology such as imaging and blood tests is vital to making correct diagnoses, given the huge variety of treatments we have to offer in the U.S., and we have come to expect at least some level of a doctor/patient partnership in making decisions about our health care. Americans expect basic comforts, including appropriate and individualized diets as well as clean and comfortable beds and rooms, which are not at all basic in Africa.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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