Teased with a laparoscope.

Wow. Today has been so very interesting and insightful. I visited one of the big hospitals in Dodoma to see the Muheza Doctor currently ‘Resident’ for his Specialist Surgical Training. I found a completely different perspective of healthcare in Tanzania. 

The hospital was stunning, absolutely beautiful. Big, newly built and, I believe, with the vision of becoming another National Hospital (the main one is in Dar es Salaam). I visited the ENT department, where they are having a new Stortz outpatient endoscopic system installed in two rooms (complete with blue lights on the coving, very snazzy) – this is better than most hospitals in the UK have. Theatres where they have two OR1 type set ups (state of the art theatre lights with built in camera that shows the surgery on a TV screen on the wall, full laparoscopic stack, modern anaesthetic machine, very new diathermy system – to be honest better than most theatres in the UK). ITU with 6 fully kitted out bed spaces to a level you would genuinely be happy to find in any UK hospital. A laboratory with new machines in multiple rooms also to rival anything that you might find in the UK. Very, very impressive. The only slightly sad thing was that it was fairly empty. It was a world away from the hustle and bustle familiar to any UK NHS hospital. There were very few patients using these services. The huge potential capacity was very underutilised. Large pristine waiting rooms in each department (with very comfortable chairs) were empty, the ITU had no patients – we earlier had seen one recently discharged being wheeled down the corridor. Oh, how I long for some of that kit in Muheza. It felt a little bit like an ultra modern ghost ship as we walked down empty corridors, empty offices, few patients….

ENT set up

Main theatres

Panoramic of ITU

Pristine but empty corridors

This is of course a project in progress, with many staff out of the country for training I am told (for example a new cardiac cath lab is looking to be the first such facility in Tanzania). It is also a referral hospital (there are two other lower level hospitals also in Dodoma), but I also suspect one of the issues is one of cost for the patients. Unfortunately, for most, treatment at such a facility is just prohibitively expensive. Even traveling to Dodoma for much of the population is, I suspect, beyond their means. Not least because there would be no family to help them (food and basic needs care is still provided by family even here). However, I did meet another group of very inspiring individuals. Doctors with a vision for what healthcare can become in Tanzania (the hierarchy here apparently leans very heavily towards the medically qualified). It seems that the main barriers at present are training of staff in specialist services together with patients who can pay for such things. For example, they have laparoscopic kit, but the only person who can currently use it in the hospital is the head of surgical services (an O&G surgeon). They all were keen to secure my return….

Selfie with the students.

(Permission to take and post)

I had come today as a curious visitor, with no intention or expectation of getting my hands dirty. However, as I was in theatre spending time with the general surgical team, it was almost inevitable perhaps that they would ask me to get involved. There was an appendicectomy on the list and they had already established that in the UK we would perform such a case laparoscopically. Of course they asked. I was a little hesitant (not knowing the team, or the kit they had) but following a visit from the head of service approving and encouraging such things as well as establishing that they had everything I would need (I vocalised a long mental list), I dutifully agreed. I feel that I have taken several such ‘jumps’ since arriving in Tanzania. Good or bad, adventurous or reckless, altruistic or insane, I am not entirely sure. But so far, they have gone well. I found myself both excited and hesitant. Could this be the start of a new laparoscopic journey in Tanzania? It was all arranged. As we waited for the patient to arrive, I was asked to take a tutorial on hernias for the medical students. How very appropriate. For anyone that knows me, I of course loved it!

And then, just as I had got my head around this exciting endeavour, it transpired that the kit was not ready and it would be 2hours from SSD. Hmmm. The patient had arrived and adopted the standard naked crucifix position on the table (she was however covered with a sheet). I examined her and was sceptical about appendicitis (despite the investigations [USS &MRI – yes they have MRI]). She was the classical RIF pain, of the like we see frequently in the UK, in whom a diagnostic laparoscopy would be perfect. Shame. Inevitably, I was asked to perform the appendicectomy. I quickly negotiated this to evolve into a diagnostic limited laparotomy (of the sort I have done in Muheza). I did not want to leave behind any diagnostic uncertainty that would invariably arise if the appendix was normal (“that Mzungu surgeon…..”).  There were some shenanigans with the anaesthetic (an initial oesophageal intubation), but with no detriment to the patient, and I (thankfully) did not need to get involved. All very routine then. The surgery went very well (normal appendix) and whilst some of the more reserved members of the team gave nothing away, I feel like bridges are being built.

I am afraid that my blue-sky thinking has gone into overload on the back of this visit. As I sit in my hotel room (very nice it is too – hot shower [cleanest I’ve felt], nice food, comfy bed with duvet [it is deliciously cooler here]) my mind is in overdrive. So much could be quickly achieved in Tanzania with a bit of collaboration and support from willing trained professionals. A laparoscopic programme could be very quickly established, all it needs is the right sort of trainers. Practice could significantly evolve. For example in my chosen subspecialty field, currently any patient with rectal cancer here gets an APER. This means that anyone with a bowel cancer within 12cm or so of the anal verge gets their entire rectum and anus removed and a permanent colostomy fashioned. This is a big deal as rectal cancer a common site for colorectal carcinoma. In the UK if you can get just 1cm clearance from the anus (some centres go lower), most people would be offered restorative surgery (ie they can still poo through their bottom)…..

….I am getting carried away with the technical (but I am excited by such things). What I am seeing, is the potential for rapid progress in healthcare in Tanzania. And for such things, you need the bar to be raised at the top end as well as at the bottom. It is the only way to generate sustainable progress. Whilst it might be easy (perhaps obvious) to say that such substantial investment could make a massive difference in the poorest and more rural areas, I actually believe that raising the top end is important too. For people to see what is possible, gives them something to emulate. Every student, trainee, or other staff member passing through such an institution would know that such things can be achieved in their country. And this is powerful. Very powerful. For me, I have quite clearly seen that there is no reason why healthcare in Tanzania cannot equal that of the west, if only it can find the right resources – financial, vision, expertise to train, logistics…. 

On the back of this trip, the hernia mesh project is also rapidly escalating…. Crumbs….

And perhaps most importantly, I have met one of the key team players for the future of Muheza. I could not have asked for more. What an incredibly kind, gentle, intelligent and inspiring individual. Whilst we did not get a chance to operate together, for some reason I know he is very good.

In his mid 40s and a trained doctor, why did he leave his family behind (wife and two children in their early teens) to spend three years as an unpaid student (he gets just a block of 28 days holiday each year to return home), working incredibly hard, living in a shared room at the university complex and paying a huge amount of money out of his own pocket for the privilege? “Because the people of Muheza need me to. They need a local specialist surgeon.”

And THAT is Tanzania.