Balcony Garden Update

Things were going great guns until about three weeks ago when the beans got some kind of blight from which they have not recovered. We were already fearing the consequences of their going three weeks without water during the looming Christmas vacation back in TN. My homemade watering system using aquarium tubing, valves and a water reservoir will sustain the healthy tomatoes and basil and mint but the speckled butter beans ( my pride and joy) are toast.

We have been surprised at how well this experiment has gone.

The speckled butter beans did not make it.

We are looking forward to the tomatoes though. Not bad for the resources we had for this project!

The Walk to Work - a short movie

This is the height of banality. Nonetheless, I had fun generating this using my iPhone's camera and a photo program that took pictures every 15 seconds. It goes by fast. Blogger is refusing to accept uploaded videos today for some reason so you will have to download the file from a file repository per the link.

The Walk to Work

Muhimbili National Hospital

Hospitals have always fascinated me. I grew up trailing my Dad around Marion County General Hospital. The uniforms, the smells and the sounds are forever embedded in my mind. Muhimbili National Hospital (MNH) has been a significant addition to my mental inventory of hospitals. It is THE national hospital of Tanzania, a country of over 40 M people. There are other at least four other large referral hospitals spread around TZ but Muhimbili occupies a unique place as the only national hospital.

"Welcome to Muhimbili National Hospital" that sits in the middle of the roundabout entrance to both MNH (to the right) and MUHAS (to the left)

There is a roundabout at the entrance to MNH and MUHAS that I walk through every day. It is also a bus (dala-dala) terminal and a taxi stand. It is an incredibly busy and chaotic place. After months I have begun to understand its rhythms. In the morning between 6 and 8 it is an absolute beehive of activity with thousands of people streaming in and out of MNH. Many people who work in our area of Dar (Upanga) come in from distant areas of Dar and get off the buses there to walk to their workplaces from this terminus. 

The Entrance to MNH and MUHAS at 7 AM

The activity level there is overwhelming most days. You see a huge cross section of Tanzanian society converging there every day. Most days it is crazy busy with people streaming in and out of the main gate to MNH to both seek care and take care of relatives on the wards. There are multiple businesses located there as well as a market for fruits and vegetables. Dala-dala hawkers are shouting out the destinations of their buses and people are everywhere.

Main Entrance to Covered Walkways at MNH

For many years Muhimbili National Hospital was the only place in Tanzania that trained doctors and nurses. It was and is the place complex cases landed. What distinguishes it currently is its nursing and medical staff. Other hospitals may have nicer facilities and may be more efficient at providing patient care but MNH has the specialist doctors and the expertise if any place in Tanzania does. Despite its limitations it remains a unique place and occupies a special place in the minds of most Tanzanians. They may love it or hate it but they know about it for sure and have an opinion about the place.

Overhead from Google Maps of the MNH campus

Medical training is a bit different in Tanzania and follows the British model generally. This was a British colony up until the early 1960's when Tanzania won its independence and their influence is still quite evident in many things. Students come to medical school straight from high school after they have done one advanced year and made the grade via a national testing system. The government tells you what your options are based on your past performance. If you are headed to professional school there are no choices except yes or no. Those directed to one profession may not cross over to another in general. It reflects the residual of the 20 year, post-independence Tanzanian socialist experiment.

Sign on the medical student dormitory by my office

First you must complete five years of medical school. Becoming a specialist is then a multi-year process with 6-7 years required post-medical school. You pay for this specialist education and are treated as a student and have classroom time and instruction as well as clinical duties. This is in contrast to the US where residents are paid but were historically worked like dogs. Frankly, the TZ residents do not work nearly as hard as US residents although that gap has closed some with recent limitations on resident work hours. The number of specialists (internist, surgeon, obstetrician, pediatrician) are limited and spots hare highly competitive. 

TZ Medical Super-Specialist Career Pathway (Nephrology in this example)

Most students need money for tuition and living expenses etc. The government "sponsors" you via a grant. It is not at all uncommon for a career to be halted for two years while you await sponsorship. Further specialization to become a cardiologist or pulmonologist etc. requires another 2 plus years. You are awarded a Master of Science degree with that and become a "super-specialist". Muhimbili is the only place in the country offering what we would call fellowships in the US. There are very few super-specialists in the country and most all of them are al Muhimbili. This is the only place where they are trained and the availability of such training is a very recent development in Tanzania.

My counterpart, Professor Magusi, lecturing to newly arrived third year medical students on the MNH campus

Families are responsible for feeding and bathing etc. their relatives daily. The hospital only provides a breakfast of corn meal porridge to its patients. Water, other food and any number of medical supplies that are not in stock are the responsibility of patient families.

Back of the kitchen where large vats of the corn porridge is prepared for patients

Increasingly patients must pay for advanced services such as imaging or unusual antibiotics or oxygen. Outside the hospital there are numerous pharmacies that provide everything from pills to IV fluids to central lines to TPN. If you cannot pay you simply do not get the treatment. Money is tight. A third of Tanzania exists below the poverty line locally and they tend to end up at MNH.

Prices for advanced imaging like CT etc. TZS 100,000 = $57. These are significant sums to the average Tanzanian. Many cannot come up with TZS 100,000. 

Typical walkway scene with family taking their hydrocephalic child to a clinic visit

Families stay outside the grounds and then come in several times a day for visitation. There is no hotel for family members. Patients from all across Tanzania may be in the hospital for months at a time. Family is hugely important to Tanzanians so someone must stay in Dar with the patient the entire time. Getting here from the distant corners of the country is a major undertaking for most (multi-day bus journey while sick) so they stay in the wards until tests come back etc. rather than return for the next phase of an evaluation as is common in the US.

On rounds with Professor Magusi, my counterpart

It is a huge, sprawling complex with five large multi-story (4) wards for OB and Women's Services, Medicine, Surgery, Pediatrics and a mixed services ward. There is also a psych hospital, a TB ward, a very busy Emergency Department and a huge facility called MOI which houses trauma (lots of that due to the proliferation of cheap motorcycles and unskilled young men who get chewed up on them), neurosurgery and orthopedics.

Typical large ward building and manicured grounds

Handwritten note on the walkway to the chapel on campus in the background warning TB patients to stay away. There is a mosque next door to it.

Patients waiting outside one of the outpatient clinics are MNH

Entrance to the Tuberculosis Ward

It is adjacent to MUHAS, the health sciences university to which Laurel and I are attached. Its campus dwarfs that of MUHAS in size. There are untold numbers of smaller speciality buildings which house things like HIV, TB, diabetes and other specialty services. Many are the spawn of past donor grants or the largess of the US PEPFAR program. There are a alliances with other international universities such as Harvard, UCSF, University of Bergen in Norway, the Karolinski Institute in Stockholm and various other universities from around the world.

Outside of an office building at MUHAS. Everything has wrought iron over windows and doors for security and theft deterrence.

It is a government facility and also serves as a major employer in Dar-es-Salaam, the business and governmental heart of Tanzania. It employs a small army of people including nurses, doctors, gardeners, aides, security, maintenance and housekeeping staff. Most significantly it has its own medical staff which is spirit from that of the academic faculty at MUHAS. They previously were all the same.

Incinerator with medical waste being sorted prior to burning. Little is thrown away if it can be re-purposed. All waste is sorted by hand to recover anything of value.

MNH outreach vehicle with Stop TB message

Covered walkways connect all the buildings and provide welcome shade at this time of year and will be invaluable during the rainy season to follow.

It is run by an Executive Director who is a governmental appointee and reports to a Board that is linked to the University of Dar-es-Salaam, Tanzania's premiere educational destination. It is ultimately overseen by the Ministry of Health whereas MUHAS, the university, is overseen by the Ministry of Education. This governance split came about over ten years ago and has resulted in increasing friction between the two entities over time.

Administrative Offices entrance on the second floor of the ED building

MUHAS is currently constructing a new university hospital for itself about 20 miles outside of downtown Dar that it intends to serve as a "teaching" hospital for the training of undergraduate nurses and doctors. Historically that has been the province of MNH. Speciality care will stay at MNH as I understand the plan. The new hospital has become "the straw that broke the camel's back" in terms of the relationship between MUHAS and MNH. MNH is starved for funding and the diversion of governmental monies to support the construction of a new hospital has been a bitter pill for MNH to swallow.

MUHAS Coat of Arms = Education, Treatment and Research

Artist rendering of new MUHAS hospital currently under construction at Mloganzila

Please note that these observations are not externally validated by anyone and represent my personal thoughts rather than those of the Peace Corps or Seed Global Health.

School Begins!

My apologies to all for the prolonged silence but we have been very busy with the return of the nursing and medical students and the resumption of classes. Suddenly there are nearly a thousand students milling around both the MUHAS (university) and MNH (hospital) grounds. White coats abound.

Students Leaving Main Lecture Halls

Laurel is teaching three courses, two graduate level and one undergraduate. She has been extremely busy with getting those off the ground. She is also regularly conducting in-service training for the nurses on the Psych Ward, something new at MNH. Nurses have a more limited role here than in the US. She has taken an educational approach to this problem. She has met with some success in trying to enlarge their role and offer the education needed to support those expanded roles. She is to be commended as driving change at Muhimbili is not an easy task we have both discovered. Like any large complex organization the systems change very slowly.

Faculty of the School of Nursing

Laurel's big news is her new office. For the past three months she has not had one. It is difficult to not have a place on campus from which to operate. However, she ended up in prime real-estate in the School of Nursing offices when she inherited the old office of the new Dean. Not bad...

Laurel in her New Office

As is my usual I am doing everything at the last moment and have been scrambling to catch up on my lesirely two months without students. I have a role in lectures and bedside instruction for both third and fifth year medical students as well as seminars for IM residents. The clinic work and ward rounds continue as before. I have started a weekly course on interpretation of chest x-rays and CT scans for the IM residents that has been fun but a lot of work. I am now making teaching rounds in the ICU and giving some lectures to the nursing staff there. There is no shortage of things of to do for either of us.

The semester started with the "white coat' ceremonies for both nursing and medical students. Then we were off to the races with multiple duties and lectures etc.

White Coat Ceremony

Professor Magusi, my counterpart, lecturing to third year students

Resources are seriously constrained here. The library is dated in terms of its holdings. Most of the materials students use are online or shared .pdf files of texts etc. Once you understand most are struggling with tuition etc you begin to grasp the level of sacrifice it takes to get where they are going. Some have some stipends from the Ministry of Education but most do not. Not everyone has a computer or internet access so their task is difficult. Most live quite a ways from campus without internet access in their hostels. There is free internet access on campus for students but the access points are limited.

Pulmonary Books in the Library. The textbook is 20 years old.

Overall I find them to be quite committed and remarkably good natured about the difficulties they face in acquiring the education many of us take for granted back home. Tanzania is a poor country with a large base of rural, uneducated peasants who survive via subsidence farming. Most lack education. Students from those families rise in the Tanzanian educational system based on merit and access to the most coveted professional training is limited. Freedom of choice does not always exist in that the government may tell bright student they are going to become a pharmacist rather than a business person regardless of personal preference. Not everyone is happy with their destination but all understand that is their only way out of poverty so they embrace the opportunities as they are presented. Most struggle due to their limited financial resources. As a rule they are engaging young people who brighten our days.

Muhimbili Welcome Sign

Muhimbili National Hospital is a huge place with seemingly infinite small buildings and nooks and crannies. I have gradually been discovering new places there as the months roll by. It is a warren of fiefdoms spawned by prior donor grants and the construction those necessitate. The long term problem boils down to this. Donors like building things with their money but frequently do not provide adequate operational expenses for the long haul. Clinical programs end up operating on a shoestring without many of the "consumables" they require to optimally deliver care to patients.  Quality facilities go unused for lack of financial resources to operate as intended.

Main Entrance to Covered Walkways

Often the Tanzanian response is to build your way out of the jam using more grant monies earmarked for construction of new programs and spaces. A new donor comes along offering monies for construction and short term operation of a new facility that partially duplicates what is going unused. You take advantage of the opportunity and build something new because it offers short term relief. Then the problem of sustainability rears its ugly head and you are back where you started but now have an additional facility you cannot operational support. This is often the only option. It is a recurring problem in most developing world settings.