31 August 2014

From the base of Kilimanjaro



Energized by the 2.5-hour church service at the Anglican Church here in Moshi this morning, I figured it was time to check in. I arrived in Moshi (Tanzania) last weekend, but my delayed checked bag stayed behind a few nights in Nairobi at the international airport. Following some local advocacy by our course administrator, a handful of patient phone calls to London, Nairobi, and Dar es Salaam, and a few clean shirt changes thanks to our course director, my bag arrived at Kilimanjaro International Airport for pick-up Tuesday evening.

We are now one week into the East African Diploma inTropical Medicine and Hygiene put on by the London School of Hygiene andTropical Medicine (LSHTM). 58 physicians are attending the three-month course. Roughly one-third are from the UK, 8 are from Australia, and the rest represent places such as Ireland, Botswana, Scotland, Austria, Denmark, Canada, Portugal, Uganda, Tanzania, with yours truly being the sole American representative.

Our course began Monday morning with brief introductions, registration, the passing out of our heavy textbook, Principles of Medicine in Africa, distribution of some bicycle helmets (in case we decide to hop on the back of a motorcycle as transportation instead of a taxi), and safety warnings. The first week focused on Epidemiology, where we reviewed the basics of epidemiological study design, had a review of biostatistics, and went in depth into the original outbreak of Ebola in the DRC. A timely topic, we thought... Our lecturer was a well-known epidemiologist and Infectious Disease (ID) specialist from LSHTM. She made a potentially dry topic interesting, and is (like many of our lecturers), an author of chapters in our reference textbook.



The mornings were spent in lecture, and the afternoons were spent in group Swahili lessons and clinical rounds. I rounded at Kilimanjaro Christian Medical Center (KCMC, our home-base in Moshi), with our small group of seven. Our Attending was an ID specialist from Cape Town who conducted bedside rounds. First, we saw a case of an HIV-positive woman with a Co-trimoxazole (Bactrim) induced dermatologic drug reaction. Unfortunately this could have been avoided as at the time she started the medication for PCP prophylaxis, it was not yet indicated. Our second patient was battling chronic schistosomiasis with resulting splenomegaly and esophageal varices. These patients end up severely anemic from GI bleeds and have a fairly poor prognosis. Lastly, we saw a patient with a history of TB, currently struggling with an exacerbation of chronic interstitial lung disease from his years of work in the tanzanite mines. My second day of rounds, we went off site to a smaller district hospital, where we saw four pediatric patients with viral gastroenteritis, rickets, tonsillitis and severe malaria respectively. Our Attending this day, was a local Moshi-based physician who claims he has an allergic reaction any time he travels too far out of the Moshi area.



In these settings, there is very limited access to laboratory tests or imaging, so most of our diagnosis was based on clinical examination and physical signs. Even though this is a tertiary referral hospital, there is no pathologist on site most of the year to read biopsies. There is a CT scanner, but it has been broken for three years. The machine to do a complete blood count is broken – and there is no back-up. These local Attendings are unbelievably impressive with what they can deduce from just a physical exam, whereas in the States we have come to rely on more costly measures to nail down a diagnosis in nearly every case.

Socially, or what our course director affectionately calls the “Hidden Curriculum,” things are ticking along quite nicely. Most of my classmates are in the middle of their specialty training and many have a wide variety of experience. A common thread however, is that they have almost all had an “elective” experience working in a developing area, and are currently taking, or have already taken, a year off in the middle of their post-graduate training to travel and learn more about healthcare in different settings. That’s in stark contrast to American docs who are in such a hurry to complete residency training for a variety of reasons. More on that later. I have enjoyed getting to know my classmates and lecturers, slowly adding in one or two at a time, hearing about their travels, their training, and their feelings on the system within which they work.

Our lodging is decent, and Thursday night we had a meal cooked at our hostel (our group is staying in one of four places around town) for $5 per person. A few from the other hostels came by, and half the group hung around on my hostel’s terrace ("Terrace Thursdays" we've dubbed it) for a few Kilimanjaros (beer) and some Konyagi (the local spirit). 





Most of the group went on safari or to stay a night at the Ngorongoro crater this weekend, but Micah, my new Irish friend, and I went out to Honey Badger Lodge for some relaxation poolside. An Epidemiology professor associated with the LSHTM based here in Moshi owns the Lodge.



We are now preparing our reading for next week’s topic – Malaria. The end of next week we will travel in six small groups to our one-week rural placements to learn about different community-level health services or projects. I’ll be headed out to Pemba, the northern island of the Zanzibar region, and most of us are eagerly anticipating the week away.


The first week was busy, but it is about to end with our hostel’s cook serving a homemade meal. What a blessing to be here – when your Sunday evening sunset looks like this, it’s easy to be reassured you are exactly where you should be.


22 August 2014