Report from Kilimanjaro Christian Medical
Center in Moshi, Tanzania
Mark Moore, M.D.
It was just like any ordinary working day
in anesthesia. After a long day at the hospital, I was now
home, digging through some anesthesiology notes. The “Dirty
Dancing” theme song was playing in the background; while
reading by dim candlelight, the shortwave radio announced
its call letters: “You’re listening to WQRT, Radio-Free
Ethiopia.” No, I would not be having supper at McDonald’s
tonight.
My interest in the ASA Overseas Teaching Program (OTP) began
in 1990 while it was still in its infancy. Its teaching aspect,
as originally arranged by Nicholas M. Greene, M..D. is what
makes it so unique among medical world assistance programs.
OTP set out to do more than just make a difference in the
lives of a few. Its goal is to eventually improve the delivery
of anesthetic care to an entire country, or even region, of
the world.
To achieve this, OTP has coordinated North American anesthesiologists
serving as volunteer teachers with pre-existing African anesthesia
teaching programs. With the proper educational assistance,
these hospitals could help create an exponential increase
in their potential to serve medical needs in the countries
where they are located.
Kilimanjaro Christian Medical Center (KCMC) of Moshi, Tanzania
is one of the OTP chosen sites. It is a moderate-sized, 450-bed
tertiary care center set at the base of 6,000-meter-high Mt.
Kilimanjaro. There are 12 different schools of training; the
Anesthesia Institute is just one of them. The Institute trains
nurse anesthetists (one year) and anesthetic officers (two
years), while also providing a year of training for physicians
prior to postdoctoral anesthesiology residency training.
The country of Tanzania, with a population of 26 million,
is located coastal East Africa, a bit south of the equator.
With a land mass equal to that of Texas and New Mexico combined,
it was formed as a protectorate after the First World War,
combining Tanganyika (mainland) with the Zanzibar and Pemba
islands. Original inhabitant of the mainland area were ethnic
groups using a “click-tongue” language like the
African bushmen. Foreign influences can be traced to the eighth
century when monsoons swept Arab traders ashore. Centuries
later, Portuguese first and then, more recently, German and
other European explorers followed as did the missionaries.
The famous meeting of Stanley and Livingstone occurred here.
Tanzania is also known for Lake Victoria, the Olduvai Gorge
(“the cradle of mankind,” where the English anthropologist
Louis Seymour Leakey made his famous archaeological discoveries),
the vast endless plains of the Serengeti, Mt. Kilimanjaro
(the tallest freestanding landmass on the earth) and the island
of Zanzibar, infamous as a center of the slave market.
All natural beauty and wonders aside, Tanzania’s per
capita income is approximately U.S. $200. The amount spent
on health care per capita annually is about $1. Disease is
rampant as is poverty, graft, widespread malnutrition and
underemployment, all of which contribute to the lack of motivation
for advance training of any kind, but especially physicians.
As a result, there is only one anesthesiologist for every
2 million people in Tanzania.
KCMC is a gem among the sands of Tanzania. It supplies trained
medical personnel for all parts of the country and beyond.
Its Anaesthesia Institute is a widely respected center of
anesthesiology for much of East Africa. The bulk of the teaching
at KCMC is done by anesthesia officers. They are paramedical
personnel who, after spending two years of training as medical
assistants and four to six years working in clinics, become
eligible for two additional years of training in anesthesia
to become anesthetic officers. The clinical workload of student
anesthetic officers and the anesthetic officer/teachers is
often overwhelming with much of the didactic teaching put
aside.
The Director of Anesthesiology at KCMC since 1983 has been
Eugene Egan, M.D., a kind Irishman with a touch of silver
in his hair, a heart of gold and the patience of Job. Unfortunately
for some KCMC volunteers in 1994, this superb teacher is currently
at the half-way mark of a sabbatical leave in Germany until
the latter part of 1994. During Dr. Egan’s absence,
S.O. Aseno, M.D., a knowledgeable and well-trained Tanzanian
anesthesiologist, is the head of the department. He is also
the only other physician, aside form Dr. Egan, in the department.
The typical day at KCMC for an OTP volunteer begins just before
7:00 a.m. It is a 10-minute walk to the operating suite where
preoperative rounds start at 7:15 a.m. Preoperative rounds
serve the same purpose as calling one’s attending anesthesiologist
at home the night before a case. The entire operative schedule
is reviewed and anesthetic management is discussed.
The elective O.R. schedule begins at 8:00 a.m. in the four
general O.R. suites and two obstetrical O.R.s, asking pertinent
questions about cases and demonstrating appropriate clinical
techniques, general and regional. Because few people wear
name tags, it is sometimes difficult to know if one is talking
to a student nurse anesthetist, a student anaesthetic officer
or even a student nurse on brief rotation through the O.R.
This can make teaching challenging, especially when added
to language and inflection barriers.
The OTP volunteer quickly realizes that the students; knowledge
base is much broader than the availability of their pharmacologic
armamentarium. At least half of all cases are done under spinal
anesthesia and lidocaine and an occasional single-shot epidural
anesthesia (no catheters are available). In the rest of the
cases, general anesthesia with halothane or, less frequently,
ether is used. Thiopental, succinylcholine, ketamine and d-tubocurarine
are the intravenous agents available. The best monitor is
vigilance as in the United States; the only other monitor
may be a manual sphygmomanometer. Palpation of the pulse replaces
the ECG. Color of mucous membranes replaces the pulse oximeter.
There is no equipment for the monitoring of end-tidal carbon
dioxide or oxygen. “Disposable” endotracheal tubes,
sterile gloves, syringes and needles are resterilized and
reused until entropy prevails. Nitrous oxide is unavailable;
sometimes oxygen is, too. As a result, one rapidly gains a
unique perspective unlike any that one has had while working
in a well-stocked anesthesiology department back home. Just
prior to my arrival at KCMC, I had finished my residency training
as the University of South Florida School of Medicine, Tampa,
Florida, under the direction of John B. Downs, M.D. The challenge
I faced at KCMC was not limited by ability or knowledge but
by the available equipment and the consideration of its practicality
to the students.
After rounds in the O.R. are finished, the OTP volunteer moves
on to the medical or surgical intensive care units. Here,
medical diseases such as malaria, encephalitis or tetanus
may be presented and discussed, the fine points of physical
examinations may be demonstrated or the art of history-taking
described. Lunch in the nearby OTP “Blue Flat”
residence where volunteers live is followed by afternoon postoperative
rounds at 2:30 p.m. It gets even darker if the electricity
is out. While working by candle or lantern, I could not help
but think that only 100 years ago, the light bulb was invented.
It was not until even more recently that the electricity to
run light bulbs became commonly available in U.S. households,
especially in rural areas. Electricity in rural Africa is
a possibility, sometimes a probability, but it is hardly ever
guaranteed. Evenings are spent preparing meals, reading or
taking a run to a small, nearby grocery for a Tusker beer
and some hot-spiced potato chip crumbs. A “big night
out” would be to go to a hotel for fresh deep-fried
chicken, to the Chinese Garden or to “Shantytown”
for grilled goat.
Journal club is held once a month on Saturday morning, otherwise
weekends are free. They are excellent times to take small
“road trips” to experience the local living and
local fare. Some of the best safari parks in the world are
only a few hours away by Jeep. Mt. Kilimanjaro, “the
shining mountain,” always looms as a snowcapped backdrop
for the KCMC grounds. There are five- and seven-day climbs
for the adventurous, but it must be done before or after your
OTP tour is completed. A short climb through its fascinating
rainforests can easily be done on a weekend. You will see
wild orchids, furry monkeys and green moss covering everything.
Climb 10 feet above the rainforest canopy and you are in stark,
dry desert. I spent one night in an A-frame cabin at 3,000
meters. Besides the temperature being near -5ºC, the
elevation makes it particularly uncomfortable to sleep (borderline
hypoxemia). Of course, 30 minutes after retiring for the night,
I needed to use the aptly named “outhouse”. Without
any light, even from stars, it was the blackest night I have
even known. I was able to use my wristwatch’s backlight
to illuminate my path. Hakuna matata (Swahili for “no
problem”).
Zanzibar Island is only a short airplane flight away. Until
my visit, the first and only time I had ever heard the word
“Zanzibar” was in the theme song of the Patty
Duke Show. From the sky, it appears to be your average tropical
island set in the clear Indian Ocean. Once on the ground,
however, it is an interesting hybrid of African and Arabic
worlds. Centuries of immigrants, slave traders, sultans, and
pirates have shaped this tiny island. The architecture is
Arabic. The streets are narrow and irregularly named. Famous,
or possibly infamous, lodgings such as Africa House and the
Malindi House can be found in Zanzibar town. It is the world
capital of spices: nutmeg, clove, pepper, vanilla beans, curry,
tamarin and lemon grass are grown here and then shipped throughout
the world. Giant chunks of spicy octopus, 3 kg lobsters and
the biggest stone crab claws I have ever seen are nothing
out of the ordinary for local dining.
During my stay as an OTP volunteer, I had the good fortune
to be part of the 21st Annual Scientific Conference of the
Society of East African Anesthetists. Hosted by KCMC, it was
presided over by its highly respected President, Nimrod Matakare,
M.D. The conference was “dedicated” in honor of
Nicholas M.Greene, M.D., described as “one of the rare
breed who has backed his vision and faith with action.”
The majority of the speakers and attendees were form Tanzania,
but others were from Germany, Ireland and Australia as well
as other East African countries. Some of the anesthetists
had travel two days by rail, Land Rover and bus to attend.
The scientific conference was coupled with a two-day anesthesia
refresher course, which extended the entire schedule to more
than a week. It all ended with a big dinner dance. We exchanged
universal war stories of daring surgeons, obnoxious surgeons
and our sickest patients. Dancing and singing continued until
early morning with no one worrying about waking the neighbors.
The following week was a preparatory week for semester examinations.
For the entire week, I gave hours of didactic lectures at
the students’ request. Topics ranged from the physiology
of the neuromuscular junction to the examination of the central
nervous system. I was also given an active par n administering
and grading both written and practical examinations. We all
spent long nights working our way through the piles of test
papers. In the end, the overall student body did well, and
the teaching staff was pleased.
OTP volunteers have a big responsibility to the teaching hospital,
its students and instructors and, finally to the entire ASA.
The goal of this program is not to encourage dependency but
to assume some of the burden of anesthesia teaching in underdeveloped
and understaffed anesthetic training programs. By teaching
anesthetists how to deliver safer patient care, rather than
directly providing anesthesia services for patients, we are
doing a far greater service to the future of the people. If
you give me a fish, you will feed me today. Teach me to fish,
and you will feed me and my family forever.
In return, the OTP volunteer receives much. There is time
to think about our physician-patient relationships and the
real reason we went to medical school and to do so undiluted
by layers of paperwork, insurance companies, lawyers and government
bureaucracy. You gain a new perspective on the true abundance
and wealth of our country, you realize the absurdity of materialism
and you dispel prejudices. There is a chance to make friends
and experience students will make it one of the most gratifying
experiences of your life.
The ASA Overseas Teaching Program is an opportunity not to
be missed. “Karibuni sana, na kwa heri ya kuonana,”
in other words, thank you for accompanying me on this journey,
until we meet again, friends!
