The following are a series of entries written by Dr. Doug Grey, former MedShare Board member and current Western Council Member, about his work at Muhimbili University Hospital in Dar es Salaam, Tanzania
Week number two began in a different way. There is a religious complex at Muhimbili consisting of a mosque on one side of the cross campus walkway, and two back-to-back chapels on the other (one Catholic, the other Baptist). I decided to visit the 6 am service at the Baptist chapel. The chapel is open air and there are permanent square cutouts in the cinder walls that allow the signing or amplified preaching to be heard well away from the church. There were about 30 attendees, a preacher, and a man on the keyboard. The roughly 40 minute service was punctuated by preaching (in Swahili, and I would not want to be on the receiving end of whatever he was preaching against), singing, and praying. The singing was to me, most remarkable: it was strong, in unassigned three to four part harmony, and absolutely uninhibited. It was what I had heard the week before. There were a few “low alto” women who were inspired. They could not have been more welcoming.
The Patient’s Family at Muhimbili
One of the striking features in all the rounds of patients we have seen in this profoundly resource-constrained country is the obvious lack of many basic elements that we associate (read as “take for granted”) with good patient care. Many of these are startlingly absent at Muhimbili. Missing items can be as simple as provisions of food, bedclothes, liquids, and some basic elements of hygiene. Service varies here; some wards are provisioned well but the public wards are absolute bare bones. I mention this as an observation, not a criticism. Much, if not all, of the shortfalls in provision of these basic human needs are provided by families. From kangas (colorful fabric coverings that provide coverage and privacy for the patients) to drinks, food, dressings, and transportation needs are all provided uniformly, unquestioning, and cheerfully by family members. I saw this time and again in the outpatient clinic. An elderly family member would require a wheelchair and assistance with the most basic needs, and there would be one or perhaps two attentive sons taking on this burden without hesitation. And this is in an environment where aids for disabled people are not required by law as they are in the US – something which we take for granted.
During the seasonal cleaning of the wards all patients are evacuated into the streets, parking areas, and parks for several hours while the wards are scrubbed. It is disarming to see the entire ward out under tents being tended to by some nurses. This couldn’t occur without the family’s help.
Muhimbili Recycling in the OR
Recycling is popular worldwide, but Tanzania takes this to a level unimaginable anywhere else. OR chairs have a variety of different looks, based on varying states of disrepair, causing one to question “What is a chair?” Is it one without a back? How about a seat and back with no legs? How about just the seat resting on a stool? All of these are in use throughout the Operating Theatre. How about gowns? How much of the gown has to be lost before it is not usable? One tie? Two ties? All the ties? These can be replaced with gauze strips (not designed for re-use) or plastic strips that have to be torn to be removed, then retied with the next use. Where does this stop? If you have to cut a hole in the gown, how many holes are too many?
Hope and Change
One obvious issue that I have not addressed in prior blogs is how the suggestions for change are received by the surgeons and whether progress is inevitable. We have experienced this directly with the two groups with whom we interact. Firm 1 is the group associated with MUHAS (Muhimbili University Hospital and Allied Sciences) populated by motivated surgeons who are open to suggestions. They have added multiple operations to their repertoire in the last few years and have adopted many of the patient care habits that Bill Schecter has been modeling through his five years of service. Firm 2 is comprised of the Muhimbili National Hospital surgeons. There are many excellent surgeons, but a few of the older surgeons are somewhat rigid in their practice as well as uninterested in any suggestion of surgical alternatives for care. The issue of tiers of quality in surgical care is not new and peer pressure is probably the strongest motivator for change. In a truncated volunteer experience where time and cases are limited, it tends to be discouraging.
Patient privacy is paramount and sacred in the United States. There is a semblance of some privacy in Muhimbili, but the very public nature of “ward medicine” make this difficult. Exams are considered private for all ages and both sexes. This is not an easy task in public wards that are overcrowded. But small mobile privacy screens that roll up and down between beds can afford this for patients, at least to the degree that they will accept exams that are essential. The outpatient clinic is different. It has exam rooms shared by two senior doctors, each with a desk separated by only a few feet. So simultaneously, there are two patients, each with family, each giving an oral history. There is a shared exam table with a small privacy screen and a small sink, and this has to be enough to get the necessary exams done. When the exam is concluded, the patient leaving is asked to call out the next patient’s name to the throng outside. The waiting room is an inside courtyard with dozens of benches along the walls lining the courtyard. The next patient moves into the room and the process continues.
In years past, Muhimbili had been “paper based” in their record keeping but have now moved to computerized records. This would seemingly be great progress for a country in the pursuit of improving care. The infrastructure has not kept up, however, and the computers lose power every 10 to 15 minutes. They have to be rebooted, and the record keeping takes twice as long. No one complains.
In my last blog, I referred to the campus maintenance legion who does their work all day. When we are walking to rounds at 6:45 am, the hospital is getting scrubbed. The dirt paths, dirt parking areas, and public spaces have already been raked to clean the leaves and overnight debris as well as trash. There must be a mile of concrete walkways that are actively being washed, mopped, and swept every morning. Dust blows all day so this is an endless task, but their commitment to this effort has paid off. Maintenance of a clean space is easier than achieving that first clean transformation. The hospital corridors are protected in the same way. Yes, it might be cosmetic, but there seemed to be a real sense of pride in the end result. The patients and their families are the ultimate beneficiaries. They have done the same with the campus gardens, but they are, unfortunately, cordoned off with barbed wire and are off limits for sitting. Too clean to use…
What’s In a Name?
When we arrived at Muhimbili in October 2014, we were perplexed by what they decide to call us and how they refer to their own colleagues. They called Bill Schecter “Prof” as a sign of respect. They referred to me as “Dr. Grey” and called Craig Lubbock “Dr. Craig” — no explanation, no reason for this difference. During this trip, it became evident that there was this inconsistency even within their own ranks. They would refer to each other by either their first, middle, or last name only, about a third of each, and not refer to any as “Doctor”. Today the explanation: their society chooses to take the simplest name – either the first name, middle, or the last name – and that becomes their name to all employees and patients. “Bosco” is the name of reference of John Bosco Ngendahayo ; “Kitembo” is the reference name of Kitembo Salum. They take the easiest name of the three and that becomes the reference name for all. Makes sense. Mystery solved.
– Doug Grey