Letters from Tanzania: July 9, 2013

Heather ZwickeyMambo from Tanga!

We’ve been in Tanga since July 4th and will be leaving tomorrow. Tanga is the first Tanzania town that I really got to explore in 2007, 2008, 2009… and it will always be somewhat special to me. Plus, my friend Pam has lived here for years, with her husband Eric, who was an octopus farmer, and her two kids. Eric has moved to Zanzibar and has been taking tourists deep sea diving, and scuba diving. Pam is supposed to join him there with the kids, but it’s difficult to leave a home that overlooks the Indian ocean. I hope she doesn’t go. I’m worried that we’ll have less excuse to come to Tanga in the future. Pam is an old soul – and she’s connected with all of the students. It helps that Pam originally had planned to go to NUNM (in fact, I interviewed her!) But then Tanzania called, and she never made it back to Portland. Her bookshelves are full of herbal medicine, energy medicine, and aromatherapy books.

In addition to enjoying the preponderance of bicycles and Indian food, the students had their first intense experience with the Tanzanian medical system in Tanga. We didn’t plan it to be intense, but from our experience with the students with last year, we knew that it might be a bit of a shock.

We divided the students into two groups. One went to the Mama-Baby clinic, and the other to Bombo hospital. The group at the Mama-Baby clinic were weighing and measuring babies, and providing nutrition education for mamas. In order to weigh babies, the mamas hand-make little harnesses out of beautiful African fabric. Babies are then hung from their harnesses on a scale that we would use to measure meat in the US. Venesh and Crane became experts at hanging babies by their harnesses, and had it down to a science. Other students were measuring length.
Everything was going well until a mama came in with her baby and they’d just been in a motorcycle accident.

Motorcycle travel is common here, as motorcycles are cheaper than cars. There are also motorcycle taxis called piki-pikis. Very few people wear helmets on the piki-piki around here. And if there is a helmet, the driver may wear it, but there will often be two or three people on the motorcycles who do not have helmets. Duke University is doing a traumatic brain injury study in Tanzania because there are so many head injuries from motorcycle accidents. At the mama baby clinic, it was clear the baby had a concussion, as well as a large laceration across its forehead.

However, the mama didn’t want to take the baby to the hospital. There is a belief among the locals that people who go to the hospital die. So she just wanted the students and our faculty to do wound care. As insistent as Maria was that the baby needed to get proper care at a hospital, the mama continued to refuse. Maria wasn’t convinced that the mama would do it after she left.

Meanwhile, Mark Miller (our MD ND faculty member) and I were with the group at Bombo hospital. Bombo is the oldest hospital in Tanga, and has been around since the late 1800s. Over the past 100+ years, the hospital has grown to include more specific departments. We visited two – pediatrics and mental health.

The halls of the pediatric ward are painted cement block. The pediatric wards contain several large rooms, each with 10 beds, complete with mosquito nets. The women lay in the beds with their infants beside them. Sometimes the women are sick, and sometimes it’s the infants. It’s a dark and sad place. The volunteer who was walking us through the ward told us that they’re struggling with babies developing septicemia about 10 days after birth, and that it appears to originate in the umbilicus. These are nosocomial infections – developing while the babies are still in the hospital from the birth. The doctors have no idea what’s causing the septicemia. Mark and I think they have MRSA. They don’t have vancomycin here, the antibiotic known to treat MRSA. How bad is the problem? Roughly 30% of the babies are developing the septicemia, and majority of them die. On the day we visited, they had 10 babies with septicemia. This is tragic in any situation, but it’s especially tragic if it is indeed MRSA that can be treated if vancomycin were available…

The walls of the pediatric ward are wallpapered in directions for how to diagnose polio. According to the WHO, there are only 3-4 countries that have polio cases right now: Nigeria, India, Tajekistan, and Kenya. Nevertheless, we’re seeing polio all around Tanzania. It’s easy to do the differential diagnosis because the acute flaccid paralysis is visible. As we were on the streets in Dar Es Salaam, Mark pointed to case after case of polio to have the students learn how to diagnose it. The student’s lesson here is that just because the WHO doesn’t know that polio is Tanzania, it doesn’t mean it isn’t here. It just means that it’s not reported. Certainly the Tanzanians know it’s here and are working to contain it.

If it could get worse than dying babies, the mental health division was worse. The space was smaller, and somewhat nicer, but the activities were sobering. We observed 12 patient visits. Of the 12, we suspected that only two were diagnosed correctly. All of the patients were being over-medicated, and mis-medicated, and drug side-effects were apparent, yet unaddressed.

The government hospitals in Tanzania struggle from a lack of access to pharmaceutical medicine. They often have one drug for a few months, and then it’s gone for the rest of the year, and it’s replaced with others – or it isn’t. It’s rare that patients have access to full courses of medication. And because many medications are unavailable, the doctors prescribe whatever they have available. In the mental health ward, this meant that patients were being prescribed anti-psychotics when they weren’t psychotic. And that after being on the anti-psychotic for a few months, when it was no longer available, they went off it cold-turkey. This practice of taking an anti-psychotic and then being pulled from it quickly can lead to problems that are worse than what the patient was originally experiencing because is messes up the brain chemistry.

I won’t talk about all of the patients, but I want you have an idea of the sorts of things we were seeing. One of the cases that sticks out in my mind is a woman who had a 3 month-old baby strapped to her back. She was given Phenobarbital for her epilepsy. First of all, epilepsy is not a “mental health” condition. However, the doctor told us that they know in Tanzania that epilepsy can lead to psychosis (i.e. seizures.) Uggg! A seizure is not psychosis! Secondly, Phenobarbital does not treat epilepsy. Usually this is what would be used as an anti-anxiety med. You may remember that this is what killed Marilynn Monroe. Finally, it was evident that the baby was being drugged. Its eyes were glazed over, and it lay salivating in the sling on its mama’s back.

Another case that upset my students and me was a 19 year-old boy who was brought in by his Muslim father. The symptoms were that he smoked marijuana, and then came back to the house happy and with a different personality. He was diagnosed with marijuana-induced psychosis and given Haloperidol – a strong anti-psychotic. For being a teenager who smoked pot… Can you imagine what would happen in the US if we put every teenager who smoked pot onto anti-psychotics????? And the thing is, the father thought he was doing the right thing. I mean, his kid’s personality changed with the pot, right? He had his second son on an anti-psychotic too. Why? Because he was nearly 30 and wasn’t interested in getting married. They had decided that he was depressed – and prescribed an anti-psychotic. However, the second son was married last week, and now they were discussing whether he should be taken off the drug. Ultimately, they decided that he should stay on it.

So who is prescribing these drugs? Someone trained in psychiatry, you’d think. But TIA. Bombo Hospital is short physicians, just like the rest of Tanzania. There are three medical schools that train physicians in conventional medicine, but very few go into psychiatry. Then there are smart people, often retired, who are volunteer health care workers. At Bombo, there is one psychiatrist, and she can’t handle all of the cases. So there is a volunteer health care worker who works with her. He’s a retired biostatistician who took a course in psychiatry. He sees many patients himself. Otherwise, the two of them see multiple patients at a time in one room. Privacy doesn’t exist here. In the villages, there are medical officers who are people who completed 2 years of medical school. What’s concerning is that the first two years of medical school are the basic sciences. So these people have very little clinical training. The students look at the state of the medical system and see very little hope for a healthy population.

Don’t worry. It hasn’t been all gloom and doom in our neck of the world. I had my first leatherman manicure! You know what a leatherman is, right? It’s one of those knife/supertools that has 40 different options of tool on it. My nails were so dirty, and I was struggling to get them clean, so Julius had at them with the saw, the screwdriver, and few other random attachments. Amelia, one of the students, called the whole process “Outdoor femme.”

And Pam got a puppy yesterday – a Ridgeback, retriever, Doberman mix. This little beast is the cutest thing, and has managed to completely enchant Mark and Greg. If you have a homestead in Tanzania, it’s wise to have a dog or two. As Jack, Pam’s eight year-old son, puts it. Dogs are better than watchmen because people like stuff, and dogs don’t really care how much stuff you have. Wise, Jack. Wise. Most people have watchmen, but Pam’s family is happy with the dogs. The new puppy will go to their place in Zanzibar. In the meantime, it’s a 7 week-old happiness inducer!

We also spent a day with Bongo Mzezi. I know I’ve mentioned him to most of you before. Bongo’s name means “Root Genius” in Swahili. He’s a local traditional healer and herbalist. Bongo is the most science based traditional healer I think I’ve ever met. He wants every one of his herbs studied. The tea that he’s used to treat HIV has now kept patients alive since 1995. Incredible what a little herb soaked in hot water can do, isn’t it? The students loved Bongo. They could feel his good energy, and spent a couple of hours asking him questions about natural medicine worked in Tanzania. Bongo described how he discovered the effective herbs either through apprenticing with his uncle (named Snake Soup), or from listening to the spirit of the plant. Several of the students would like to come back and preceptor with him. We’d also love to collaborate with him, I’m just not yet sure how. An Irish student wrote his thesis on Bongo and some of his herbs. Perhaps some of our students will choose to do something similar.
And today, the students gave public health lessons at the local village elementary school. The Tanzanian children are always so excited to play with the medical students – it’s lovely to see the connection.

The elementary school leaves a little to be desired, as you can imagine. There are 700+ students there, and 16 teachers. There are 135 students in the kindergarten – in ONE classroom. I love the way that the teachers get the kids to stop talking and gain control of the classroom though. They start clapping in a rhythm, and the children join in. It’s awesome. Next thing you know, you’ve got 130 kids engaged, and awake. I think this may work on medical students too. I’m going to do an experiment when I get home.

What’s unique about this school is that it has a special ed room. It’s very unusual for Tanzanian schools to have special ed. Usually the special needs kids are hidden away from society and ostracized. This school has decided that to embrace them and has one teacher devoted entirely to the 22 special needs kids – which is saying something when they only have 16 teachers! If you heard the teacher for the special ed kids talk, you’d grimace. By American standards, he is far from politically correct. But he has the best of intentions, and that has to be appreciated.

Tonight we’ll have a BBQ at Pam’s house, dance some, drink some, and then head out to Moshi tomorrow.

Sending love from Tanga town!