Teule Hospital, Tanzania
Edward Armstrong shares his many varied experiences of his time in Tanzania
My elective was spent in Teule Hospital, Tanzania from September till November 2007. Teule is based in a small town called Muheza which is situated in the rural north-east of Tanzania near Tanga and some four hours north of Dar-es-Salaam. The climate can be warm and humid as it is just one hour inland from the Indian Ocean but also temperate as the town is situated at the end of the nearby Usambara mountain range. This variety leads to wonderful wildlife with all kinds of colourful insects, monkeys and blossom that inspire many of the designs of the local women’s shawls and head-dresses.
The hospital itself somewhat typifies many rural African hospitals. There were two paediatric wards, two female and two male wards, one labour ward, a theatre, x-ray department, a pharmacy and a laboratory. As is a familiar story across the region, there were deleterious shortages of doctors, nurses and skilled laboratory technicians. In fact, there were only five qualified doctors being well led by Dr Sally Edmonds, a UK gynaecologist who was sponsored by an Anglican missionary organisation. The doctors were supported by many clinical officers, who had usually received about two years training, and many student nurses from the local nursing school.
I arrived at the hospital with two close university friends and was warmly welcomed by another group of elective students who were leaving that week. We settled into our accommodation which was inside the grounds of the hospital. This was fairly basic with infrequent running water and electricity although we were provided with fans and mosquito nets in each bedroom.
During the first week I shadowed Dr Edmonds and helped with antenatal clinics. These ran along similar lines to my own obstetric placement in the UK and I was soon allowed considerable freedom to examine many pregnant abdomens and check blood pressures. Most interestingly, a young 17 year old woman came to clinic with a noticeably large ‘bump’ which an ultrasound scan later showed to be triplets. I also helped in obstetric HIV clinics which had been especially set-up to reduce the mother to child transmission rates. Those taking HIV medications were generally very good at adhering to the treatment regime and had been well counselled and educated throughout their pregnancy. Finally during that week I was able to assist with the elective caesarean operating lists and to practise some basic surgical skills under supervision.
The first weekend, we travelled to Tanga, a large but sleepy town on the Indian Ocean. Our intention was to start writing our MTAS forms (job application) and we needed to travel to a major town in order to get internet access. With warm evenings and beautiful ocean views, the setting was not conducive to filling in job application forms however by Sunday we were surprised by our progress. We vowed that we would indulge during the weekends following the submission deadline.
I spent the next few weeks in the hospital with the surgical and anaesthetic teams. This provided a fantastic opportunity to get involved with the necessary procedures such as spinal anaesthesia (this being better than giving a general anaesthetic which would require continual manual ventilation of the patient). At times, I wondered about the ethics of some of the care that was provided to patients. Epidural needles were inserted with no prior local anaesthetic and the doctors supervising encouraged me to try as many times as necessary in order to place the needle in the correct space. On questioning, the response was always, “we can’t use local anaesthetic otherwise the patients will start demanding it and then what will happen if we run out of stock?” My impression was that this pragmatic, realistic but tough attitude had come from hardened experience and the continual exposure to severe illness and death that is not so frequently seen in many UK hospitals.
Despite the lack of resources available to the surgical staff, they were good teachers who were willing to give time to the elective students. Many of the theatre sessions reminded me of the atmosphere in the UK with continual banter between the surgeons, anaesthetic staff and the theatre nurses. The presence of several London medical students simply served to stir the joviality.
Common operations included hernia repairs, haemorrhoids and other bowel procedures. In addition, orthopaedic procedures were common due to the high road traffic accident rate. Most interestingly was the weekly vesico-vaginal fistula operating list. These fistulas result from prolonged and obstructed labour which can result in a hole between vagina and bladder meaning that women may continually leak small amounts of urine from the vagina. The operations repairing these fistulas were not complicated but had infinite benefit to both the women and the economy as these previously ‘outcast’ women were now able to rejoin society.
In amongst this excellent time in hospital, I travelled at weekends with friends to the coast to enjoy the fantastic isolated beaches and sea around the area of Pangani, an hour south of Tanga. I was able to go snorkelling and sail out to uninhabited islands just off shore and return to freshly caught seafood meals. My colleagues and I also had the relief of finishing and submitting our job applications and we decided that with that out of the way, we would travel up to Arusha, to see Kilimanjaro and to go on safari for the weekend. It certainly was quite a contrast to life in the village and hospital.
Having returned to Teule, I spent the remaining time with the medical team. The male medical ward had a huge range of patients with varied pathologies. Commonly there were patients in heart failure, a result of previous rheumatic fever, or with infections such as malaria, TB and of course AIDS. The acceptance of AIDS patients was in contrast to the commonly held attitude that the African stigma regarding AIDS has hampered public health attempts to overcome the disease. Unfortunately however, HIV treatment and prevention is never far from politics and conversations with some of the hospital doctors suggested a strong pressure from the US PEPFAR (President’s Emergency Plan for AIDS Relief) initiative not to promote condom use or distribution.
The end of this medical ward week concluded the official elective period and we left to enjoy a few days relaxation on the island of Zanzibar. It certainly provided a exceptional finale to my elective.
To conclude, I must acknowledge the enthusiasm, assistance and hospitality extended to me by my hosts in Tanzania, particularly the staff at the hospital. For those planning their elective, I can highly recommend Teule. In terms of medical exposure, cultural exchange and innovative thinking, the elective provided me an opportunity second to none. The elective occupies something of a unique place within the medical curriculum and should continue to be strongly supported, despite recent changes in medical training, as the freedom extended to medical students on elective broadens horizons and reminds one of their passion for medicine.
Edward JL Armstrong
Final Year medical Student
Imperial College London
London, UK
edward.armstrong@ic.ac.uk