My project in Tanzania involves facilitating linkages between the Muhimbili University of Health and Allied Sciences (MUHAS) in Dar es Salaam and the Bagamoyo Health District, about an hour drive outside of Dar. It is intended to be a collaborative relationship in which MUHAS and the District both meet specific goals, such as offering students experiential learning and an understanding of health care services in the districts, continuing education for District staff, and hopefully, encouraging students to consider a career in outlying health districts where there are severe shortages of health workers.
Bagamoyo is the oldest hospital in Tanzania, with the oldest buildings in use dating from 1895, when Bagamoyo was a relatively important city in German East Africa. The hospital has expanded over time, but the bulk of the buildings are seriously out of date, and equipment out of date or non-existent. Supplies are variable in their availability.
My arrival at Bagamoyo had challenging timing. The District Commissioner arrived at the same time to fire five people for "fiscal irregularities." It is difficult to imagine that anyone could steal from a facility that is limping along trying to meet community need. In a country in which corruption is an every day occurrence, it seemed a good thing that people were being called on their actions (while at the same time I wondered about the underlying politics). The activities of the day put my hosts on edge. My primary contact person was called into a series of meetings, so he put me in the hands of a young physician to continue my tour of the hospital and assessment of facilities.
I was quickly impressed with Dr. Kyoro. He is new to the hospital, one of only a couple available physicians, a recent MUHAS graduate, has a high level of personal commitment and energy, and is filled with ideas. He is from a small village near Kilimanjaro, enjoys the variety of patients seen in a small facility, and is committed to being at Bagamoyo for 2-3 years until he might get government sponsorship to continue his medical education and specialize in obstetrics and gynecology. He hopes to then return to Bagamoyo. First, recruiting a doctor to a district hospital is a very big deal (or having them at all). Second, someone like Dr. Kyoro could also be a spark to help the hospital make much-needed changes. High on the list of those changes is the operating theater.
The operating theater needs to be replaced to be able to offer services the district needs. It is nearly impossible to really clean, windows are broken and covered with cardboard, the operating table saw better days decades ago, anesthesia is an old ether diffuser with no monitoring equipment, there is an old and weak suction machine, the overhead light does not work, and the surgical recovery area is in a vestibule in the small building including an entrance door to the outdoors (literally a table behind the door), and another outside door to the bathroom and wash tubs/clothes line. The vast majority of surgeries done are emergency cesarean sections, and they are forced to refer many cases to hospitals in Dar, which takes a great deal of time and is at a cost that most cannot afford (recall discussions about transport - it is always challenging). Women do not come to the hospital for normal deliveries. It is, however, not unusual for women to experience extremely long labor periods, sometimes many days in length, and which can result in fistulas . There are no data on surgical infections, but my guess is that the rate is fairly high.
My focus expanded into gathering information about what it would take to update the operating theater. As there is unlikely to be government funding available for new facilities and equipment, this would also require seeking donor funding. It is a long shot, maybe, but a new theater would significantly improve the quality of care and health outcomes in the district. The hospital does have notable bright spots, including a terrific HIV/AIDS program, an area in which there is quite a lot of international funding, and including a great voluntary counseling and testing program. I was impressed by the very good availability of HIV drugs (some extremely expensive in the US, like Atripla), and a home-based care program. This said, HIV drugs generally still reach only those who are most ill in the country (in the US, the current standard is initiating treatment upon diagnosis of HIV infection, while people are healthy). Unfortunately they don't have the lab equipment necessary to monitor the impact of HIV drugs on body systems, like liver function. Most drugs outside of HIV are not funded from elsewhere (with the exception of some malaria drugs), and their cost is the responsibility of patients, often making them too expensive. The hospital is also in need of antibiotics, which brought my thoughts back to surgical infections.
There is much work to be done and it is clear that significant assistance also needs to come from outside the hospital, and probably from outside the country. The task is huge on the one hand, but there are also relatively small changes that can be made that would significantly shift health care quality and community health status. Maybe even sooner rather than later.
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