Monday, March 2, 2015

Update #4 from Med/Peds Resident Ryan Fabrizius during international rotation in Arusha, Tanzania

Pole Jambo from Arusha!

Since last writing I have been rounding on the medicine ward, which has been quite a different experience compared with pediatrics. While malnutrition and respiratory infections malign the infants and children, HIV devastates the adult population. Surprisingly, non-communicable diseases are just as common, if not more so, than HIV and its complications. Diabetes, hypertension, and chronic obstructive lung disease (emphysema) are much more common that I expected, and, unfortunately, with the transition of local populations to urban lifestyles, they will likely become the major burden of disease in developing countries like Tanzania. Just as it is in the US, chronic disease is difficult for patients to understand and providers to feel like they can make a difference, but I have been impressed by the knowledge and compassion of the local doctors to not just treat but to educate their patients on how to manage chronic diseases. For example, in outpatient clinic this week, I sat with Christopher, the internal medicine registrar, as he took about 30 minutes of a busy clinic day to explain diabetes type 2 to a patient. The concept of disease occurring without symptoms and not having a one time solution is a difficult one to grasp, but Christopher patiently reached for common ground in understanding. Despite the myth that doctors in developing countries are "paternalistic," I have found that in this case and many others, doctors like Christopher strive to educate and empower patients and families to understand their condition and proactively participate in their own care.

For today's Swahili lesson, I wanted to introduce the word "pole." Just like "karibu," pole is a common and versatile word that enters into interaction several times per day. It is usually used here for "sorry," like when you bump into someone or walk on a clean floor with dirty shoes (I seem to leave a trail wherever I go). "Pole" also has some unique uses that we have observed. It is considerate to express "pole" when you see someone carrying a heavy load (we get a alot of "pole"s when we carry groceries home up the hill). Many people will say "pole la kazi" when they see people at work, whether working at the hospital, harvesting roadside crops, constructing/digging, etc... It means, literally, sorry about the work. It feels similar to the feeling of sympathy medical residents give each other during a busy night shift or after a difficult series of events. To me, it seems to be expressing, "I have been there and I feel your struggle, hope you get to finish work and rest soon". 

The most interesting use of "pole" for me has been with patients. When most local medical staff approach a patient on rounds or clinic, they usually begin with "pole bibi/babu/mama" (sorry grandma/grandpa/mother), which acknowledges the fact the patient is having a struggle. The usual response is "asante" (thank you), which feels like an expression of gratitude for recognizing the burden on the patient and family. As medical workers in the US, I think we do recognize the value of this sort of sympathy. Some useful expressions that I have learned from my teachers are "this seems like a difficult time for you" or "i'm sorry you have to go through this," but usually this comes up after a display of emotion from the patient or family that beckons validation. In clinical practice here, I find it most interesting that this validation and sympathy is the greeting, rather a phrase reserved for certain situations. It seems rooted in the community values here, that one person's burden is shared amongst others, not just friends and family, but all people that interact with them. Here in Tanzania, there are so many burdens that people carry, even in daily struggles for basic needs. It is frustrating for me, as someone that takes for granted that my daily needs are easily met, to see the barriers that people have to providing for themselves and their children. On top of that, the burden that HIV, chronic disease, and other medical conditions place on an already struggling people seem absolutely insurmountable. This, for me, stirs up feelings of injustice and unfairness, questions of why? and how?, and often results in frustration and fatalism. But for the people here, they bear with each other in these circumstances, supporting one another and carrying one another's burdens. Linguistically, I do not know if these words have a common root, but "pole pole" is another common expression that means "slowly" or "gradually". It is the unofficial mantra of climbing Mt. Kilimanjaro: gradually, one foot in front of the other. And such is seems with bearing one another's burdens. Sorry for your troubles, but slowly, together, we will carry it together.

Walking to Selian Hospital with Mount Meru in the background

Monday, February 9, 2015

Update from Med/Peds Resident Ryan Fabrizius during international rotation in Arusha, Tanzania

Hamna Shida
Jambo from Arusha! This week, I did my last week of pediatric wards with the all-star team led by Joseph (the registrar- a role like our senior residents) and Dr. Steve Swanson (a pediatrician from Hennepin County Medical Center, now serving at ALMC and Selian full time) and comprised of Kahema (the intern), Sasita and Baraka (the two Assistant Medical Officer students- a role like physician assistant students). It has been a great experience working with this team, and I have been so impressed by their eagerness to learn, compassion for patients, and their cheerful attitudes. Joseph, as I have mentioned earlier, is one of the best assets at Selian Hospital. The registrar is a position given to an MD upon finishing the one year rotating internship and can be an indefinite position, or often one taken while seeking out a residency spot in a specialty. Their role is to attend on the wards and to supervise the interns, though there are many duties they fulfill behind the scenes such as teaching the AMO students, participating in hospital administration, and seeing patients in OPD (outpatient clinic). There are 4 registrars currently at Selian, all of whom are excellent, but Joseph stands above the rest in his medical knowledge, enthusiasm, ambition, and compassion for the community he serves. He actively pursues solutions to "upstream" problems that lead to the sad conditions that we often see: malnutrition, difficulty with accessing care early in the disease course, and recurrent respiratory infections. He often purchases essential supplies with his own money and stays late awaiting tests that return hours and hours after they were requested. He hopes to gain a residency spot in pediatrics this next fall, though this is a difficult task in Tanzania, since there is not a steady source of funding for these positions. Either a trainee has to pay their own way, which is thousands of dollars per year, or they must obtain a sponsorship from the government, church, or pursue an international training program. It would be a loss for Selian when Joseph leaves, but we truly hope for his success as a pediatrician, a field that is greatly underresourced in a country with greater than 50% of the population younger than 15 years old and two pediatric residency programs. 
Though learning Swahili has been quite slow for me, certain phrases seem to be preferred by different people. I have already discussed "Karibu" and the greeting ritual, but we noticed fairly quickly the phrase most preferred by Joseph. "Hamna shida" (no problem) is mentioned in almost every interaction with Joseph. For Lion King fans, this phrase is a close cousin to "Hakuna matata", though for some reason wasn't chosen for musical glory; perhaps because matata is more fun to say. Examples of it's uses include responses to: "Joseph we don't have any oral rehydration solution and we don't think we'll be getting it anytime soon", "the family cannot afford the antibiotics you recommended", or "all of the thermometers have disappeared". He uses this phrase so much that Hope and I have taken to calling him Daktari Hamna Shida. To an observer, I think this phrase could be generalized to represent the people of Tanzania as laid back, care free, no worries. The slower pace of life, simplicity of material possessions, and emphasis on relationships here fit this mantra well, but one might easily interpret this as laziness compared to the frantic lifestyle we pursue in the Western world. I have seen, though, that there is a different usage for people like Joseph. I really do not see him and others like him resigned to be worry free in the midst of a community suffering under the weight of poverty and it's ghastly burden. "Hamna shida" is not permission to avoid reality, but I think it is one way to accept reality but not to let it frustrate or corrupt. Though I am clearly frustrated with the lack of resources that I take for granted in the practice of medicine in the US, Joseph is able to see what is lacking but to not give in to despair. For him, it seems, "hamna shida" is a recognition of factors beyond control and a challenge to strive for the best for his patients with the resources available. I truly hope that places like Tanzania will someday have the infrastructure and resources that all people deserve, but I am encouraged by people like Joseph who are able to overcome these circumstances and to make Tanzania better.

Ryan's Hamna Shida pose

Dr. Steve Swanson's new NICU at ALMC

Path en route to Selian, with Mount Meru in the background

Registrar Joseph with Intern Christelle, blowing bubbles from soap and a plastic wand we gathered for a malnourished child with multiple readmissions

Arusha Part 2, by Global Health Chief Resident Hope Pogemiller working in Arusha, Tanzania

Greetings once again from A-town! 

The past few weeks have flown by, and it feels like a whirlwind.  Days are filled to the brim, and I quickly slip into sleep each evening under the comforting canopy of mosquito netting. I gaze at the 1 inch hole to my right, reminding myself that is not large enough to permit entrance of the resident African Hedgehog or the domestic mouse/gecko who leaves gifts in my sink every evening.  Hamna shida. Hamna shida (no problem). 

I've grown close to 2 registrars (doctors who have graduated medical school and 1 yr of residency "intern year") and a few interns.  A few of our sicker patients' families wave and greet me with big smiles around the hospital campus.  These patients and their families speak Maasai, and it is always a little search to find a nursing student or aid who speaks both Maasai and Kiswahili to help communicate at the bedside. Thankfully, greetings and warm feelings have never necessitated a common language.  I feel particularly fond of my older patients.  I've been rounding with the Internal Medicine team for the past 2 wks, and we have had a very low census.  We have a few people in their 30s-40s with gastritis or malaria, and then we have people in their 50s-60s with HIV who are on or off of anti-retrovirals and present with clinical pictures consistent with TB or PCP.  The group of patients that I particularly enjoy are those > 65 years old.  The women often have COPD from years of cooking in an enclosed home with smoke. This often leads to cor pulmonale, and they present with heart failure and/or COPD exacerbation.  One patient in her mid 70s was quite ill, but she greeted me each day with the most beautiful, relaxed smile. Each day she would report to me about her status in Maasai, and then we would begin the search for someone who spoke Maasai and Kiswahili.  My patient and her family recognized quickly that speaking to me in Maasai led to perseverance until we interpreted her message all the way to English and addressed her concern.  It is not an expectation that the medical staff update the family/patient each day as in the States with bedside rounds, but the internal medicine registrar with whom I work is particularly devoted. I watch him including the family in conversation and educating the patient whenever possible.  I often watch the family members during rounds and report to him when they seem frustrated or confused. He immediately takes them aside and explains in more detail or asks them what's on their mind.  He has this calm, quiet, comfortably-paced speech that looks to be greatly appreciated by the patients.  This past week I have learned much about the Tanzanian healthcare system and perspectives from this registrar and a few interns.  Motivations for choosing a career in healthcare vary, as in the States.  The unreliable timing and amount of paychecks for doctors is accepted, while steps are taken for improvement in the future.  In the meantime, the majority the doctors and students with whom I'm working have this thirst for knowledge and need to help those around them have an improvement in their lives.  This core desire combined with an intense community spirit is something incredible to witness.  When I am able to contribute in my part, I am instantly enveloped in this community.  It's hard not to feel very grateful for the opportunity to live here for a few months, making the world just a little bit smaller.

We had 20 international expats visiting for a field trip during a class last week, and it was interesting to hear their thoughts and impressions of Selian Hospital.  One doctor noted that it would be easy to know what to do if we only had the resources here.  Discussion with other expats from Minnesota and the graduate of MN residency who began the 2 hospitals in Arusha has covered this territory.  Loads of supplies have arrived at the hospitals in the past, yet they are not found when needed in the process of medical care.  It would be silly to think they would be used exactly in the same manner as in their country of origin. The key is to creatively think through the pathophysiology of the illness at hand and apply resources in unique ways.  It is not too uncommon to hear expats complaining that Tanzanians often have an external locus of control or learned helplessness... not looking to improve situations when barriers to advancement or success are encountered.  I suppose I am am growing more and more certain that human nature is universal.  Culture just wraps up the variety of personalties in any group with different colors, papers, and ribbons.  We had a diabetic patient who took 1 mo of metformin and then did not have access to a refill of her medication (or maybe didn't prioritize it as highly as healthcare providers might).  It is difficult to adhere to a diabetic diet anywhere in the world, but more so in her community.  We were injecting subcutaneous insulin to cover her high blood glucoses, and she was requiring much lower doses after when it was difficult to find food at the hospital.  We found a way to be sure she has food (not all carbs), and we checked her blood glucose three times daily.  One morning she had no blood glucose reading in the chart, and the nurses had not given her her injectable insulin as they had no glucose reading to doublecheck.  We had finished our supply of glucose monitoring strips. The registrar and intern and nurses immediately shook their heads, explaining to me the problem and adding that this is unacceptable.  There are shortages of medicines and supplies at all times, but certain essential supplies and medicines were simply necessary.  The administration of the hospital has a very open door policy, and the intern and registrar walked over to explain the situation. Calls were made, and by the end of the day we had a box of glucose monitoring strips.  Where was the Tanzanian inertia-- the inability of Tanzanians to identify a problem and find a solution?  Experiences like these give hope.  This is the way to future improvements in the system, and the intervention was wholly Tanzanian.  We have nicknamed the exceptional pediatric registrar at Selian Daktari Hamna Shida (Dr. No Problem), as it is his most common phrase.  Instead of panicking and making a ruckus everytime he notes an "opportunity for improvement," he calmly voices his mantra. Hamna Shida. Hamna Shida.  You can see him beginning to brainstorm, and later he can be found in the cafeteria or under a tree with hospital administration discussing the situation and working on a sustainable solution.  Although it might appear at first glance that he is simply dismissing medication and supply shortages, he is carefully working toward improvement with an eye toward sustainability.  People recognize his value, and he is given much respect.  As others follow suite, it is possible to see improvement on the horizon.  Cautious optimism shared among hospital staff.  Cautious optimism allows for perseverance in the face of adversity-- even if the adversity is deeply engrained corruption to the core of the country.  

Ryan and I have been able to try to understand together the current status and future of healthcare at Selian during the beautiful walks to and from Selian each day.  We alternate between learning kiswahili numbers and body parts, greeting fellow Tanzanians sharing the path, and interacting with schoolchildren learning English.  We vary our greetings, trying not to miss anyone...with the responses we receive sounding something like this... "poa, mambo, poa, mambo, jambo, jambo, poa, GIVE ME MY PENCIL!, jambo, jambo... " The spontaneous humor from our neighborhood children never fails to send us chuckling. Creative responses are very appreciated, and we now shout back requests for anything from a book to a bag. Our colleagues from New Zealand have even inquired about the price of a large cow being herded by us on the path.  Some days are more frustrating than inspiring, but one thing we can always count on joyfully unpredictable conversation en route to the hospital each day.

I hope this message finds everyone healthy and in good spirits -- Hope

Pictures from the walk to Selian, with Mount Meru in the background of the last two pictures

The ALMC Health Center (open air greenery in the center of the hospital complex)

Looking at an x-ray outside the male IM ward

Arusha Part 1, by Global Health Chief Resident Hope Pogemiller working in Arusha, Tanzania

Greetings from Arusha! 

As the children energetically yet patiently teach us each day, Jambo, Mambo, and Good Morning Teacha are just a few of the many acceptable salutations offered to everyone encountered.  This reflection of intense community spirit is a welcoming reminder of the incredible value of universal salutations and the respect they engender.  It's wonderful to be back in the land of long walks, random chats with new people, and compulsory salutations.  It is remarkable how respectful these children are with playful greetings and light conversation in Swahili (which I can pretend to understand by judging the nature of their smiles).  Some roll tires or bike wheels alongside us, greeting us in Swahili, trying a little English, or just smiling and staring up at us a little-- without chanting and only rare demands for money.  They seem to be accustomed to living with Mzungus, and they enjoy interacting with us as real people.  The 6 km walk to work is hilly, but it has been a delightful form of exercise with the accompaniment of schoolchildren.

My flight through Amsterdam found me a new batman wristwatch, and my voyage was only slightly delayed with de-icing in Amsterdam prior to departure and a little intense visa discussion at the airport. My taxi driver waited for me for a few hours, and he looked purely relieved to see me...the last person from my flight out of the airport.  I tried to explain the need for de-icing the planes in Amsterdam, but it was a complication that seemed rather peculiar to him.  As we walked to his taxi, his buddies at the airport all shouted out to him that they were glad he found me.  There was so much support and no irritation for my delay-- a lovely introduction to this culture.  We had a lovely chat en route to Arusha on a beautifully paved road.  My "host-mother" Linda (the wife of the doctor who moved here after residency at the U to start 2 hospitals) met me at my house around midnight and gave me some keys and a phone along with some basic orientation.  Linda is an effervescent woman with a heart of gold and a creative, quick wit that is a pleasure to experience.  She drove Ryan (med/peds resident staying in Arusha through Feb) and me to the " Pic n Pay" Middle-Eastern Grocery Store for one of the most lively grocery visits I've ever experienced.  She gave us a tour of the 5 aisles and greeted every third person whole-heartedly (they were close friends) as she shopped and advised us on our shopping.  It was a great introduction to the community, and it was followed by a visit to the Dutch fruit/vegy vendor.  We pulled up to the gate and noted that it was closed, but she was not deterred.  She found a way to slide open the gate and walked in to ask what their hours were.  It was 5:58, and she thought it had closed 2 minutes early.  She came running back to the car in a minute to tell us we could enter to buy food.  The market had closed at 5, but the vendor was more than happy to welcome us to buy some of the most delicious mangoes, avocados, greens, oranges, and tomatoes.  Arusha is a very large city, but Linda has delightfully created a tight-knit community that suddenly gives it the feel of a warm, small town.  Today we heard that she took out a few of the medical students from New Zealand cheese shopping, which caused a instant pang of jealousy and regret.  The Linda fan club is vast but devoted, and I can't wait to meet with her again!

We met with Dr. Mark Jacobson and Dr. Steve Swanson, toured the 2 hospitals of Arusha Lutheran Medical Centre and Selian, and have now had an opportunity to follow interns, registrars, and AMO students on rounds at Selian.  There has been talk of the creation of didactic sessions such as morning report and case presentations. However, presence during daily rounds and coaching with the ultrasound machine seem to be of particular importance for the hospital staff at Selian.  After a few more days learning the system, I plan to ask some of the staff what their needs are and try to match them with my skills to pave a position for the UN global health chiefs in the future.  In the meantime, I'm thoroughly enjoying refreshing rains, long walks to the hospitals on bumpy dirt paths surrounded by bright green foliage, banana trees, palms, and corn fields with cows herding by, the same African dog calmly watching, and an endless stream of energetic children walking to and from school and fetching water.
Sunset en route to Kilimanjaro Airport

One of the many beautiful hibiscus bushes blooming in front of our house

A pretty, but unlucky bird with a blue tail who slammed into our window and temporarily sat dazed under our porch chair

Ryan (aka the Flash) joyfully running from our house in the morning on the way to work 

Med students from New Zealand and Ryan, walking back to our house

Purple flowers marking the outside of our house

Friday, February 6, 2015

Final Blog from Chiang Mai, by Med/Peds resident Kristina Krohn during international rotation in Chiang Mai, Thailand

I can't believe it is my last week here. Was it really almost 6 weeks ago that I sat on a plane next to a professor of art history and scholar of Burmese religious objects, while on my way to Burma/Myanmar before coming to Thailand?  Besides being able to pick his brain about the historical sites and religious relics I should see in Burma/Myanmar, he introduced me to a different medical concept: that the government health care system could be the best health care system, even with a good private system.
This professor spends part of his life living in Thailand and part in the United States. He chooses to get his health care in Thailand due to the cheaper price tag. But it is more than that. He also chooses Thai government hospitals over private hospitals, because he says they are better.

I know Thailand is known for medical tourism, such as high quality sex change operations, joint replacements, cosmetic surgery, etc. Any elective procedure you can think of, you can find a boutique hospital in Thailand that caters to tourists looking for a cheaper option, generally in a hotel/resort type atmosphere, fully including relax time on a beach. 

But a government hospital? Where the money does not go to fancy beds, decorations or iced latte's?

The concerns in the United States about a socialized, single-payer health care is that it will decrease the quality, increase wait times, and provide poorer healthcare than our current system.  Although, working in the current system I still see the people who don't ever get care, the minorities who get worse care, and that US health outcomes are poorer than most of the high-income world.  But, put that all aside for a moment.

Recently the Veterans' Affairs' scandal about faked numbers and long wait times encouraged the belief that a federal medical system in the United States would increase wait times.

My own previous experience in Uganda was that government hospitals were considered worse than private hospitals. In Brazil, a nice upcoming BRIC country, where the government hospitals don't lack supplies, the physicians still wanted to work in the private sector to make more money.  They wanted to receive their care in the private sector, because that care was "better".

What made the care better?   The doctors and nurses had more time to see patients, and they didn't need to wait a long time. 

I wasn't certain I believed the professor that here in Thailand things were different. Yes, Germany, Sweden, the United Kingdom, Canada, and other very high income places have top notch national health care systems. But Thailand?  I knew they had great doctors, but had assumed that outside of universities they migrated to the private sector as well.

After seeing an Australian-Thai dual citizen who flies back to Chiang Mai to get his health care at the government hospital because he also thinks it is the best care he can get between the two countries, I decided to talk to the Thai residents.

Fern responded quickly, "I want to work in a government hospital." No hesitation.

"Why?" I asked.

"Because you get to see more interesting patients. You see everyone. You see lots of poor people, so you see lots of disease."

Ok. I can see that. That is part of why so many people like working at Hennepin County Medical Center (HCMC) and the University of Minnesota.  You see cool things that you just won't see other places. But what about for her own care? I continued, asking, "Where do you want to go for your health care? Where will you go if you get sick?"

"Here," she responded again without pause. "The best doctors and nurses are here. I would want to be taken care of here."

"Not at a private hospital?" I asked, just to be sure.

"A hotel? No, no."  Then she and the fellow began describing private hospitals as places that pay more for the decorations and the atmosphere than the medications and the doctors. Many of those places are for falangs (foreigners), and the care is not as good as the care you can get through the government if you are Thai. So why would you waste your money that way?  The overall impression was that it would be silly to go anywhere else.

I have a hard time picturing some of my wealthier patients in Minnesota being willing to get their care at a Thai hospital. I already had a suburban Minnesotan tell my attending that they would never get their care at a place like HCMC. Thankfully, my attending responded by saying that the patient would be lucky to get his care at HCMC if he had any disease that needed more than the small community hospital where we were.

But maybe if people knew it is where the best doctors were, if it were incentivized so that the best doctors wanted to work there, a government system could work somewhere like Minnesota.   I think it has potential, but I also think it would be a hard pill for many Americans to swallow.

Martha Montgomery, IM Resident on international rotation in Kampala, Uganda

So if you’re in Kampala, specifically if you live in the upscale neighborhood of Kamwokya (ky pronounced ch) and you find yourself unable to sleep at 3:18 in the morning, you’ll find that this is the quietest time of the day. It’s still not perfectly quiet. There’s still the incessant dog conversations going back and forth among the houses but Otis, our neighbor’s dog, at least seems to be asleep so it’s a distant barking. There’s also the sound of traffic, like an interstate nearby, only I know logically that there is no interstate. There’s only cars driving at excessive speeds taking advantage of the paved roads of the city and the lack of traffic at three am, and yet it is still a ceaseless flow of traffic. There’s an occasional boda (motorcycle) engine but otherwise they’re quiet at this hour. The birds are quiet too and the international rooster has not yet woken. Being in a decently sized metropolitan area, you have to try to listen for the rooster. He’s not immediately outside my window like he often is. As many others have found, the rooster is a universal barometer of just how urban your setting is. Perhaps universal urbanometer would be the more appropriate nomenclature. If someone were to study roosters around the world I’m sure she could find a significant correlation between the proximity of the nearest rooster and the reliability of internet, electricity, running water, paved roads, or ability to purchase any number of international foods (be it Thai, Greek, Mexican, American, Italian) by phone and have it delivered (thank you to your door. All of which is to say that living in Kampala has been quite easy. I have a great many things to be grateful for and many people who were invaluable in helping me settle in (namely, Darlisha, Darlisha, Darlisha, and not to forget Wendy, Mahsa, Nathan, Josh, and so many others).

Writing in public is to me an exquisitely personal endeavor, and I’ve always been impressed by how many others do it so easily. I’ve never been much of a Facebook-er. I often forget to check it (possibly because people seem to post with a frequency that is inversely proportional to how well I know them). And from the other end, I don’t have much interest in sharing what’s on my mind only to have it remain viewable in perpetuity. What in the world would I have to say that could be so remarkable? But I find myself being chided by a certain former global health chief, and so here I am, examining my reflections in writing. If I knew how to say, “not so remarkable” in Luganda I would instill that as the title of my entry.

So what am I doing in Kampala? Much as I am a one face in the throng of 2-ish million people in Kampala, my role here is a small cog in a much larger apparatus. My background in epidemiology and working on large cohort studies is just enough to keep me afloat (barely). The Infectious Disease Institute where I’m working is a powerhouse of clinical research and a “Center for Excellence” for cryptococcal meningitis. It has a feel that is equal parts Ugandan and International. My clinical skills, on the other hand, feel woefully inadequate as I have come to rely on the crutches of advanced chemistry and microbiology and sophisticated imaging (none of which I can perform on my own, I might add). Left alone we have the history and physical exam which, as we know from morning report, leaves an awfully wide differential by 8:30am. By 8:45am the advanced laboratory and imaging results have swept in to save the day. Here at Mulago Hospital we’re left guessing after the 8:45 mark. So we guess at treatment and watch day to day as the patient either gets better or worse. Of course this happens in the US as well, Mulago just seems to take it to a new level.