Update #3 from Global Health Chief Resident Hope Pogemiller working in Arusha, Tanzania

Habari ya Tumaini

So, it’s been quite a while since I’ve written.  Life has become quite busy, and I have wanted to be thinking clearly before sitting down to write to everyone again. Today I realized I’m not sure I’m one to think clearly…linearly…  So, I’ll write a little on a more serious note.  Life seems so much more serious when you are freezing in the house with fuzzy socks and heavy sweater shawl in place and with a cup of tea.  (Yes, I know it’s 73 degrees. But, can you really put a number on “cold?”) As the content herein will be serious, I’ll attach a few pictures in a lighter vein. 

I’ve always quite liked sea slugs, and as it is the rainy season, slugs are abundant. One of my pastimes has become stalking slugs and taking pictures in the foliage.

One of my favorite people from New Zealand posing with me in the matching skirts we had made

My favorite New Zealand couple with me at a fabulous Ethiopian restaurant

F75 is a dog living near the canteen at Selian who was quite malnourished in January as she was breastfeeding her puppies. We named her after the initial formula fed to children with severe acute malnutrition—F75.

View from one of my flights with the flying medical service to transport patients from the rural areas of Tanzania to a hospital. The pink dots are flamingoes

More flamingos

One of the planes was owned by Wings of Hope previously… but I found the tail comforting ;)

Another view from one of my flights

In my short time in Arusha, I’ve been impressed with the lasting, positive impact made by the revolving door of residents and medical students at Selian and ALMC. They arrive with eyes wide open and energy. There is a general eagerness to help in addition to learn—many are surprised that they have plenty of knowledge to share with medical trainees.  The knowledge gained when visiting Selian and ALMC extends far beyond the sheer volume and serious medical acuity of patient interactions.  I watch as people absorb the community-centered culture and are introduced to the medical system headed by a government who has a strong desire to provide affordable care to the vulnerable populations as well as those in upper socioeconomic status.  This idealism is a laudable goal, but lack of resources in necessary areas results in a medical system for the vulnerable that seems to limp along at times.  It can be discouraging operating within this context, with a serious lack of trained medical personnel in the country.  I think this is one realm in which cultural exchange can be quite valuable.  The influx of positive energy and new eyes analyzing dilemmas from clinical cases to medical systems to clinical education promotes patient explanation from Tanzanians which spurs creative new ideas and approaches that help in the brainstorming process that can “fight the unbeatable foe.”   This truly helps to subdue that nagging feeling that your team is simply “rearranging deck chairs on the Titanic.”

On a more personal note, friendships form quickly here, and many of them continue after resident/med student departures.  Likewise, it’s been very encouraging to find consultants in the US who are happy to help with tricky cases despite the lab and imaging limitations.  Forging friendships and professional relationships between hospitals in Tanzania and between specialists across countries is one path to a brighter future in the realm of medicine. 
I feel honored to work with so many Tanzanians and expats who are deeply devoted to medicine and the improvement of lives for individuals and the population as a whole.  It is not infrequent to feel incredibly inspired and unbearably frustrated simultaneously.  The rollercoaster of life somehow seems more intense here than it might elsewhere.  As in any medical practice, some weeks are much more discouraging than others in terms of patient outcomes.  However, keeping a list of patients who left the hospital or clinic with a clear improvement in health has been invaluable.  As in the US, debriefing with hospital staff and families is cathartic for all parties involved.  

Update #2 from Internal Medicine Resident Elizabeth Gulleen during international rotation in Damak, Nepal

Hello again from Nepal. Things have settled into a bit more of a routine here and I am now working full-time at Life Line Hospital, where I will spend a total of 3 weeks.  Clinical responsibilities include rounding on the inpatient medicine wards inpatients and working in the outpatient clinic (OPD). Census varies from 3-10 inpatients and 15-30 outpatients seen daily.  The work is done by three internal medicine physicians who divide the responsibilities (including overnight call) equally.  In Nepal, internal medicine is a subspecialty that requires 3 post-graduate years of training.  Physicians must first complete 4.5 years of medical school to receive their MBBS, complete an intern year, and pass the national exam medical exam. The applications with the top 10-20% of exam scores are eligible to complete a residency and become consultants.  As there are limited training spots in Nepal, people often go overseas to China, India, or even the Philippines for advanced training.   Ideally, the physicians then return to Nepal to practice, but often the lifestyle and pay in other countries is preferable and so the physicians will stay in the country in which they train. 

Often we come to tropical countries to study the “glamorous” infectious diseases such as filariasis, leishmaniasis, or malaria.  However, this rotation has been a good reminder that non-communicable disease has truly become a global epidemic.  While I have seen a number of TB patients, I have yet to care for a patient with malaria, typhoid, or dengue.  At least 60% of the patients in OPD present for treatment of hypertension, diabetes, or hyperlipidemia and the chronic sequelae associated with them. Inpatient admissions for hyperglycemia and COPD exacerbationsm are common.  Nepali physicians face universal challenge of teaching the importance of chronic-disease management.  Unfortunately, all too often, patients will chose to treat their hypertension with herbal medications and do not have the resources to use life-long medications.   Consequently, it is not uncommon to have patients present with heart failure, strokes, or myocardial infarctions after years of untreated hypertension or diabetes.  The physicians spend much time with counseling about the importance of ongoing medical management and state that they are gradually seeing improvements in medication compliance and understanding of chronic disease.  However, they see this as an ongoing challenge which will take years to improve and feel a responsibility to continue the endless fight against disease.  

Taking a break from clinic duties to watch the cricket world cup. (Yes, I have tried to Wikipedia my way to understanding the game at least three times. No, I still do not have any idea of what is going on.)

The costs of basic laboratory and consulting services at Life Line Hospital. For reference: 100 rupees is about $1 USD.

A view of the outpatient department courtyard.

One of the physicians teaching some medical officer students during a busy emergency department shift.

Update #2 from Internal Medicine Resident Matt Goers on International Rotation in Uganda

For the past 2 months I've had the pleasure of working with IOM Uganda. When I arrived in mid-January, I didn't quite know what to expect, but when I walked into the IOM Kampala ofice I was overwhelmed by the number of warm and friendly people I encountered (as well as all the food). My first week in Kampala was a mixture of getting to know the way IOM works as well as shadowing the IOM physicians and staff. I got to sit in during refugee screenings and meet applicants for resettlement from Somalia, South Sudan, Rwanda and the DRC. They had some incredible stories, and by the end of the first week, I was already loving my work. 

Our first trip out to a refugee camp was to the Nakivale Resttlement camp near Mbarara, Uganda. This would be my first visit to a refugee camp and also my first experience participating in refugee relocation screens. We spent nearly 3 weeks screening over 500 patients, and I quickly started to see the purpose for the screenings. We found people with pneumonia, tuberculosis and Burkitt’s lymphoma. We found people in need of mental health services and newly diagnosed pregnancies in need of further obstetric care. I saw how powerful it was to help someone through a new illness, but also move towards a new life in the process.

After Mbarara, we came back to Kampala for only one day before being whisked away to Kyenjojo, Uganda for another mission. This time, we screened around 250 refugees, and began to work on a side project further evaluating applicants who were found to have abnormal findings during their examinations. During a previous IOM mission to the Kyangwali camp near Hoima, Uganda, providers had noticed that nearly 1 in 6 refugees presenting for medical screenings had enlarged spleens. During our mission to Kyaka (near Kyenjojo, Uganda) we found similar findings in Congolese applicants, and by the end of my trip, had begun working on a project evaluating for potential causes in the community. 

It wasn't “all work and no play,” however, and during my time in Uganda I had my fill of new experiences (and new foods). I learned a little Swahli, Lugandan and Somali from some of the refugees and staff, and sampled a lot of the local cuisine (even trying matoke for the first time). Dr. Gladys made sure I was never hungry, and Dr. Saul made sure I was never bored or without a good laugh. During the last week in Kampala a few of us even took a day trip to Jinja, Uganda to see the Nile. We got to go rafting over some of the rapids, and I’m proud to say I stayed dry despite the Nile’s best efforts (mostly). 

I keep telling people what an amazing experience this trip ended up being, but I haven't been able to fully explain it to people back in the U.S. Maybe it has to do with the work we were involved in, helping refugees relocate and start a new life. Maybe it was getting to immerse myself in a new culture, and finding some new friends in the process. But I think what was truly extraordinary about my time was that I never felt like I left home. I had the distinct pleasure of getting to work with a group of people who treated me like a part of their family, and who made sure I never wanted for anything and even humored my silly questions and comments throughout my stay.

I left Uganda with a heavy heart. This experience has to be one of the most rewarding and fascinating experiences of my life. It is possible, though, that somewhere down the road I’ll see some of these refugees in the United States. Many of the applicants I met will be eventually relocated to the U.S., and some may even come to call Minnesota home. If I do see them again, it will just add to the long list of amazing experiences I've had from Uganda. We'll have to find some matoke somewhere in the Twin Cities.

IOM vehicle outside of Mayanja Hospital in Mbarara, Uganda

View from apartment overlooking Kampala, Uganda

Panoramic of Nile River from balcony