My main enjoyments of medicine so far have been surgery, so I was keen to go somewhere where I could experience surgery in a different setting and see other types of medicine. Going to a third world country was always on my list because I have never experienced the types of medicines utilized there. Zanzibar, being a small island with one main hospital, Mnazi Mmoja, therefore sounded ideal. Finding out the hospital was right next o the beach and being in the Indian Ocean was also a small incentive!
The population of Zanzibar is 800 000 and growing1. Zanzibar’s health system is funded primarily be government sources, although there are external sources of funding. Private hospitals get their funding elsewhere. The life expectancy here is an astonishing 48 years2.
My first day at the hospital began with a stark introduction into the healthcare system in Tanzania, as well as an orientation around the wards. On first impression of the wards, I could not believe that it was medicine it’s most primitive state being used. The more I saw, the more fascinated I became with how much clinical medicine is relied upon here, and how fortunate we are in the UK to have the NHS system and not have to pay for simple tests such as blood tests or urine dips. These each cost around 1500 shillings, which equates to approximately 80 pence. For some families these tests are paid for but only in life and death situations – literally.
The most common cases I saw on all wards are listed below;
This is the leading cause of outpatient and inpatient health service attendance, and the leading cause of death in both children and adults1. On my first day it became apparent how prevalent Malaria is, based on how often a patient was diagnosed with malaria.
Most cases were due to malnutrition or secondary to ‘malaria’. The phrase ‘this patient has anaemia secondary to Malaria’ bacame a standard to expect at the end of every clinical assessment, regardless as to whether or not the patient had a positive Malaria screen.
After speaking to a government official on the island regarding the effect that HIV was having on the island of Zanzibar, he explained to me that the government here is investing a lot of time and money into researching how HIV awareness can be promoted and how HIV itself can be prevented/treated. Here in Zanzibar the HIV treatment is free as part of a government initiative to increase the amount of people receiving treatment and being aware that testing is available for free.
I began in the surgical department, were my first impressions of the surgical theatres were grim. At a glance I might have mistaken the area as a scene from a torture chamber. It is the most primitive medical setting I have seen, yet I was surprised at how much successful surgery occurred at Mnazi Mmoja. There were no sterile fields, and scrubs for seniors were ironed in the theatre waiting area.
Having found a consultant who seemed keen to teach, I found myself on the orthopaedic ward much more than I expected and thoroughly enjoyed it. Orthopaedics seems to be one of the medical professions in which there is a minimum standard; even in the 30°C heat, the orthopaedic surgeons still managed to be the sharpest dressed people in the hospital with the three piece suit. As for the profession itself, orthopaedics were one of the most advanced types of medicine I saw for a ‘third world country’. Granted the theatres were basic and the equipment did not consist of the flashiest gadgets the surgeons could get their hands on, but the level of skill and knowledge was on par with western medicine. Fractures are set or surgical realigned if needed, and open fractures are cleaned in a sterile environment, but there are no positive pressure areas in theatre.
In my first week on the surgical ward, a teenager was admitted and rushed straight to theatre as the only survivor of a car involved in an RTA collision with police car. The orthopaedic surgeon had the job of repairing 7 broken bones in both legs and setting his left arm in plaster. The surgery lasted only three hours and the patient was put into multiple tractions whilst he remained in ITU.
It shocked me to see this young boy in traction after such a horrific accident, and his only mode of pain relief was with an anti-inflammatory (Diclofenac).
My next two weeks were then spent on the paediatric wards; I found myself sadly becoming less affected to the tragedies of children dying here on a daily basis. My first experience of this was whilst waiting for a ward round to begin in the nurses’ office, and realizing there was a baby lying under a kanga (basically a sarong) having died the previous night.
The bonus to paediatrics was the heart clinic. In the UK infants with serious heart defects are treated much younger than they are in Zanzibar ,and as a result we have less clinical exposure to these signs and often don’t gain the experience of listening to such a varied degree of heart murmurs. I feel that this was a large advantage of my elective and now feel slightly more confident in listening to abnormal heart sounds. I also saw several cases of serious hydrocephalous. These patients were not treated when neonates and no shunts were inserted. Plastic surgery is possible, providing the family were able to afford sending their loved one overseas for treatment. The worst case of this was a two year old boy who could not physically support the weight of this own head, it was larger than two rugby balls put side by side.
As part of my elective I took part in a maternity audit project which I arranged to do in collaboration with the LINK-Z project prior to going to Zanzibar. Anyone going on elective should consider this, as it is a great thing to have on your C.V, and is easy to complete over a few afternoons on elective.
After speaking to one of the midwives, she explained that as part of the LINK-Z project, obstetric consultants from the UK come to work at Mnazi Mmoja for months at a time. She said this process has given the ward more structure and guidance on how to run a maternity ward. It appears to me that the LINK-Z project has been detrimental to the improvement of this particular ward.
Many students, like me, begin our elective expecting to make a difference in a third world country and to be praised for our every effort. In actual fact, we probably hinder the system by slowing down the ward rounds and clinics by having explanations as to why things are done differently, not to mention the translation issue.
Mnazi Mmoja is a friendly and vibrant place and I made some great friends there and now have a full appreciation for clinical skills/ clinical diagnoses.
For more information on Mnazi Mmoja and carrying out your elective there, email Dr Omar at the hospital on firstname.lastname@example.org. The hospital fees are $75 per week. I would advise taking a few pairs of scrubs to wear whilst in hospital, as it gets very hot. Other students were told to bring white coats before hand, but they get very hot and none of the staff there mind what you wear. Accommodation is sorted through the hospital and costs around $15 per person per night – it is basic but clean. They often come with a living area, balcony and kitchen, however it is dirt cheap to eat out; 75p can get you a decent meal where the locals eat. Be warned most accommodation the hospital set you up with does not have air-conditioning and a mosquito net is a must have!
In conclusion I cannot emphasise how progressive this elective was in increasing my clinical skills, as well as my knowledge for tropical diseases. I found that due to the lack of resources such as simple blood tests (which we take for granted in the NHS), I had to rely on my clinical knowledge a great deal. My elective most certainly made me much more appreciative of the NHS system ,well as the extensive training our doctors must go through.
For anyone thinking about an elective in Zanzibar, I can’t think of a better place to experience a different kind of medicine with the prospect of seeing all kinds of weird and wonderful. As part of our time out from medicine, my friends joined me on my last week to enjoy the beaches after climbing Mount Kilimanjaro. Between the four of us we raised £4000 for three different charities, (although I must add that climbing the last seven hours ascent of Kilimanjaro was like ‘climbing out of hell’, so perhaps I’d advise medical students to skip that part of the trip or take plenty of chocolate to keep your spirits up!) The disruption of the volcanic ash clouds that played havoc with incoming European flights was an added bonus… I can’t think of a better place to be stranded than the Indian Ocean.
Warwick University, UK.
- United Republic of Tanzania PDF Government document. Available at: http://rbm.who.int/wmr2005/profiles/tanzania.pdf
- LINK-Z project Presentation about Zanzibar at a World Health Organisation meeting. Available at: www.who.int/social_determinants
- Zanzibar government Ministry of health and social welfare 2009. Tanzanian government website. Available at: http://zanzibar.go.tz
- World health organization (WHO) website. Available at: http://www.who.int/countries/tza/en/