Musings on the bus….

We just made our extraction to greet the bus this morning. It was a close call however, with an unusual complete meltdown by one of the smaller team members (who shall remain nameless), almost grounding the adventure for two of us. It was impressive. And whilst as a parent in the thick of it, it is horrendous, a part of you is also quite impressed by the depth of emotional outpouring. Although very difficult not to lose your temper (I might have done a touch…) To be fair, at crunch point (and I genuinely thought I would be staying behind in Muheza), when said team member was presented with a critical ‘should I stay or should I go….’ decision, an excellent choice was made. That out of the way, and despite having to wait anxiously for a very late arrival of the bus, the remainder of our journey was interesting and surprisingly painless.

We were somewhat bemused to be asked to change busses halfway through our 6hr journey, stopping in the middle of nowhere (savannah not far off desert) – we assume so that the drivers can return to their home ‘port’.

There are a number of things I could say about the change of landscape as we ventured north towards Moshi. Firstly, it became increasingly more ‘westernised’. Subtle, but undoubtedly by the time we arrived in Moshi, the buildings were more substantial (several with more than one story, some even multiples!). Also, the shops were more recognisable as shops and there was a definite feeling of an increasing wealth. It made us realise that where we are in Muheza really is fairly rural. Another notable thing was that the mud changed from an orangey burgundy to a brown, more familiar with European soil. Interesting!  

The bus journey also gave me some time to unwind. Inevitably in that process however, there are a number of outstanding clinical things that came to mind from my first 5 weeks of work here…. Has it only been five?!?

As I reflect on these first five week, I am genuinely astonished by how much we have done. It has been massively challenging (how many times will I say that) but also so very rewarding. I have captured much of this in my blogs to date. However, there are many aspects to clinical practice that I am finding hard to work out how to progress. For example, one troublesome condition that crops up on an almost daily basis is BPH, benign prostatic hypertrophy, a big prostate in layman terms. A pathology that usually has a very streamlined pathway in the UK, has very limited options here currently. It tends to present late, frequently with men in urinary retention. Patients often suffering for several days without passing water – gulp! The management at this point is easy, catheterisation. Things start to get a little bit troublesome when a urethral urinary catheter fails, as the technique for inserting the alternative, a suprapubic catheter, is fairly traumatic for all involved (as I have previously described in an earlier post). However, it is from here that things become particularly tricky. Because there is no next step. Most of these patients end up with a catheter for life. Access to medication or surgery is very limited. TURP does not exist here and open prostatectomy (offered in a few referral centres) is very expensive and thus prohibitive for all but a tiny minority. The whole situation is most unsatisfactory. I am currently working with the local pharmacy to see if we can get hold of the essentials of finasteride and tamsulosin. Just getting these basic medications would make a massive difference to the local population. Probably freeing up many from the burden of a long-term catheter (at least for a period of time). Surgical options… well they go into the mixing pot of my scheming mind for the future….

There are other cases too that are pretty heart-breaking. For example, the 19year old girl with sickle cell anaemia who limped into the clinic complaining of hip pain. My concern was that she had suffered with AVN, avascular necrosis, of the hip bone as a result of her blood disorder. Essentially, this is when the blood clots in tiny vessels causing part of the hip joint to die leading to irreparable damage and horrendous arthritis. These concerns were confirmed on x-ray. In the UK this would be pretty devastating news for her as she would need a hip replacement. A big operation for a lady of her age. Here however, the news is horrendous. 

We are not even sure whether a hip replacement is possible in Tanzania. If it is, it would be on a price scale that would be so far beyond the wildest dreams of the average citizen, it might as well not be available. Breaking this news to her and her mother was tough. And there was a part of me that was angry. I was angry that for this beautiful young woman, the life ahead of her was one of pain and progressive disability. She has no options. Compare and contrast that with the many thousands of people who undergo hip replacement in the UK every year. And this doesn’t even touch upon the morals and ethics surrounding causality of disease in these wildly different healthcare systems. Her only hope is that at some point in the future access to such surgery might become possible. But we are a long way from that.

But I must kick back at this point. Release myself from the burden of clinical practice (well try at least) and enjoy a well-deserved break over Christmas.