Our first day of clinic, which I had intended to have been a bit lighter to enable the residents to learn the EMR here, not to mention practicing neurology halfway around the world, had somehow been kidnapped by the gremlins and turned into a bit of a free for all. I guess the saving grace was that having survived it, there wouldn’t be much that the residents wouldn’t be able to do going forward. Having gone back into the hospital late last night to review the CT on the ataxic child, it had been a late night for everyone.
Tuesday and Thursday mornings over the last several years have been reserved for educational lectures at 7:30 am that are given by the volunteers and are attended by all the clinicians here unless they are away for their annual holiday or in the operating theatre. In the early days, I used to give these lectures myself, but have found that the residents, being the great educators they are, are perfect for this job and typically enjoy doing so. Depending on the number of volunteers in other specialties that are here during our visit, we’ll usually get a slot a week for the residents to give a talk. Dr. Ken is in charge of the educational lectures and, having already checked in with him on my arrival, he’s told me that we have Thursday of this week to deliver a lecture and we’d go forward from there.
Our lectures are those that can help the generalists here at FAME better take care of their patients, not only on how to treat the more common neurological disorders they will see such as headache, stroke, epilepsy, neuropathy, and such, but also which patients they should plan to send to us while we are here, or at least which patients they should seek help with. The challenge for the residents, of course, is to make sure that their talks are tailored to practicing medicine in rural East Africa. The threshold for ordering tests here will be much higher both from the standpoint of availability of the technology (ordering MRI scans on patients doesn’t serve much purpose here when there is only a single MRI in all Northern Tanzania, and it is two hours away from Karatu) and the affordability of the test for the patient. MRI scans are incredibly inexpensive by Western standards (approximately $200), but when you are in one of the poorest countries in the world (Tanzania ranks around 17 out of 195 countries in the world for GDP and its average annual income is around $1200 though we are in one of the poorest regions of the country), the cost of a test may be more than what a family makes in an entire year!
In addition to being sensitive to the available technologies, the residents also must be aware of the available medications we have here in Tanzania. For example, there is a new class of medications, the CGRP-inhibitors, that have revolutionized the treatment of headache in the western world and which we are using on a daily basis back at home, but none of these are available here given their high costs. Putting these in one of your talks would be useless as they will very likely never come here, or at least not in the near future. Likewise, for stroke, what has become commonplace in the US and the rest of the west, thrombolytics, or clot busters, are not available for the treatment of stroke here. But in this case, it is not only the cost of the medication that limits its use, but also the fact that it can’t be administered with a CT scan as there can be no bleeding present when it is administered, otherwise it will likely kill the patient. There are so few scanners available here that it is unlikely that a patient has had a scan until they possibly reach a tertiary center.
And then there is the issue of time with thrombolytics as they must be administered within three hours (or 4.5 hours in certain cases) of the onset of symptoms or the risk benefit ratio changes and it’s no longer beneficial to give the patient due to the high risk of bleeding. The distances one must travel to reach medical care, often on foot or by private car, would make this impossible for the vast majority of the population within the country. Further complicating the picture is that there are virtually no emergency services available here in the country. There is no 911, EMS, or paramedics that will come in shiny ambulance with its light flashing when there is an accident, or someone needs emergency help. That is all done by private citizens here, so when there is some catastrophic event such as a bus accident, which has happened on several occasions here in the recent years, victims are loaded into private vehicles by those individuals who have showed up at the scene.
The main purpose of ambulances here is to transport patients from a health facility to a center with higher technology that can more appropriately care for the patient. And these are all private ambulances that provide this service as there are no government services in this arena. When we travel here under the auspices of Penn, we are provided evacuation insurance for illness, but that only gets us from a major health facility back to the US. It does not provide transport from the bush (and that would include Karatu and FAME) to a place where we could be evacuated from, and, because of this, I purchase evacuation insurance for every resident, faculty, or medical student joining me here through AMREF Flying Doctors that will provide this service and is an absolute necessity.
Today’s lecture was on emergency medicine and was being given by Dr. Amanda, who is an emergency medicine physician from Australia and will be spending the year here along with her husband, Pete, a pediatrician, and their two small children. Their services are being supported through an Australian non-profit and the timing could not have been more perfect as FAME is about to complete a ten-bed emergency room, long in the planning and quite necessary for the region we are serving. This will provide dedicated space with up-to-date technology and allow FAME to care for patients without having to take up room in the clinic or the wards for these patients. Up until now, we have been seeing these patients in a small, two-bed emergency room that has also doubled at various times as our neurology clinic when we’re here and our endoscopy suite when necessary. On those occasions when we were utilizing the space, it was always a bit awkward having to make room for an emergency (separated merely by a room divider) and continue our neurology visit. Though emergency rooms exist here in Tanzania, they are typically seen only in the larger medical centers in Arusha and Dar es Salaam, and emergency medicine is a new and upcoming specialty that will certainly grow in the coming years with the help of physicians like Amanda and facilities such as FAME, who are willing to be at the forefront of this technology.
Our patients for the day certainly ranged the gamut for diagnoses, both in the pediatric and adult arenas. As usual, epilepsy occupies perhaps the largest swath of those patients seen and is one of those areas in which we can be the most effective. We realized quite early here that epilepsy held a very special place among those diagnoses that we treat here given the number of patients who suffer from this very treatable condition and the complete lack of physicians (i.e., neurologists) in this county to treat them. Hence the importance of our program at FAME as we are here to teach the primary healthcare workers (doctors, clinical officers, and nurses) how to manage this illness given the fact that not only are there few neurologists to treat the patients, but there are also no neurologists to teach the doctors and nurses in their training programs. Ninety percent of epilepsy exists in low to middle income countries which is exactly where there are no neurologists. The number of neurologists in high income countries is far more than 100 times the number that exist in low-income countries and that lack of neurologists in the countries where they are most needed can be felt in Tanzania as many of these patients have never sought care for their epilepsy or the care they’ve received was ineffective for so many reasons.
The impact one can make in situations such as this, where there is a complete mismatch of patients and resources (i.e., doctors), is more than phenomenal and would be awe inspiring for even the most cynical of us. Simply taking an accurate history, examining a patient, and placing them on the correct medication can be so life-changing for them that one quickly realizes the impact of our being here. And these are the easy things that require no new technology or even new medications, but just the know-how and the willingness to be open to the possibility that we can make a difference in the world. Most importantly, though, we can teach a man to fish and capacity build in the process of doing so, multiplying the effect we can have many times over by teaching those who are willing to learn from us. This is ultimately the mission of FAME, The Foundation for African Medicine and Education, with the emphasis being the last word of its name. The purpose of our being here is to teach, though a by-product of our being here is also to be taught and lessons that we learn are immense. One cannot help but to take away from this experience a much better understanding of who we are, and that the world does not revolve around us, but rather that we are an integral part of something that is much bigger than any one of us.
We saw two very classic idiopathic Parkinson’s disease patient who were both doing well on carbidopa-levodopa, the very same medication we use in the US, and even though there are many other fancy medications we could try which are not available here, we can make do with what we have. We also saw a patient presenting with a progressive cerebellar ataxia and was undoubtedly suffering from one of the spinocerebellar ataxias, a group of conditions known as “the SCAs,” and are genetic disorders of which there are many. There are no treatments for them, either here or in the US, and each has its own constellation of features and clinical course. Determining which of the SCAs it might be is an exercise that certainly is important and rewarding, though only from an academic standpoint (an apology to Stephen Pulst who has devoted his life to researching these). Even though we had nothing to offer the patient from a treatment standpoint, it is important to recognize that what we can provide them is an explanation of why he is having problems and hopefully prevent them from continuing to visit doctors looking for a reason why and spending more money and time in doing so, which would only be an exercise in frustration.
The day was again incredibly rewarding to the residents for they accomplished a great. I believe that we had seen about 26 patients or so, certainly nothing to sneeze at. Everyone was becoming more comfortable with the process here, from the residents who are seeing patients to our translators working in a team with the residents. Our translators, by the way, are all clinicians. They are mostly clinical officers, or the equivalent of a nurse practitioner, though perhaps even more independent, and so they have a very decent knowledge of clinic medicine. In fact, I will typically defer any final decisions regarding a differential diagnosis or treatment plan until they have had a chance to weigh in on the matter. Dealing with things like cutaneous anthrax, or brucellosis, or Tb of the spine, are not things that we run into on a regular basis at home and they are something that a clinician here is much more likely to think about than us.
We had a lovely early evening back at the house with a cool breeze on the veranda and everyone sharing stories from their very full day. As the sun slowly set and the sky turned a light orange on the distant clouds, I believe each of us was quite pleased in our own way for FAME, Tanzania, and Africa in general is such a place of wonders that it is hard not to feel you have somehow arrived in paradise.