Mervyn Dean on palliative care in Tanzania

Mervyn_DeanIt would be a stretch to say that I have now adapted to the African way, but after three weeks here at the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania, I am getting to do some of what I came here to do without, as far as I can tell, upsetting anyone in the process. The change to my program that I arranged is working and some of the staff are getting to know me and what I want to do.  Having said that, palliative care is a very unknown quantity here and so many do not know what it is or, worse in my view, incorrectly believe they know what it is. One physician thought it was long-term care and wanted me to look after his 16 patients with traumatic paraplegia. A junior physician approached me with great concern because I had seen a patient who was waiting for transfer to the Ocean Road Cancer Institute in Dar es Salaam for radiation therapy. “How can we send her if she’s getting palliative care?” she asked.  Even after I explained that palliative care would provide needed comfort for her while awaiting transfer she (the physician) still had difficulty understanding that active treatment and palliative care are not mutually exclusive.

KCMC was built about 50 years ago. Coincidentally I had brought with me to read “Three Cups of Tea” by Greg Mortenson and David Oliver Relin. I was quite surprised to read that Mortenson’s father was a major force behind the establishment of the KCMC, and his mother behind the founding of the nearby International School in Moshi (ISM). The hospital looks old, and so does much of the equipment, including the beds. It could do with “freshening up” but it is not dirty – the housekeeping staff seem to be forever cleaning the place – and the staff work hard to care for their patients. But it is very different from Canada, of course.  The surgical ward in particular, and the medical ward to a lesser extent, are overcrowded.  Six-bed rooms have 10 beds in them plus two or three cots or beds down the centre.  Both sides of the corridors on the surgical floor are lined with cots. By contrast some of the other wards have empty beds. I haven’t been able to find out the official number of beds that the hospital has, but the figure quoted to me is around 450.  An equally uncertain but believable figure for the average occupancy is over 600. 

Sadly, there isn’t an alternative for these patients. KCMC is a major referral centre with a medical and nursing school, and several other training facilities for allied healthcare professions. I’m told that some patients specifically request transfer or admission to KCMC, and certainly none of them complain about the overcrowding, although my Swahili is minimal and I rely for such information on the physician, nurse, or student (medical or nurse) who is acting as interpreter.  Their presence gives me the chance to do a little bedside teaching, whether they want me to or not.

A lot happens that frustrates me. Patients and/or their families have to pay for much of their care, including lab tests and some drugs. I haven’t quite figured out yet what is free and what is not, but some patients have to forego needed treatment because of their poverty. Today I saw an elderly man with known cancer who had presented with florid symptoms and signs of spinal cord compression. Both the surgery to decompress the spinal canal and the radiation treatment that would be needed are only available in Dar as Salaam, an eight-hour drive away that the patient has to fund.  This man cannot afford to pay to go there, and so will become totally paraplegic.  To be honest, he presented at such an advanced stage that he is unlikely to get much improvement as a result of any definitive treatment but at least he could be spared progression of his condition.  I felt really frustrated, but both the physician with me and the patient accepted this as normal.

“No Hurry in Africa” I quoted last time.  I still spend a lot of time waiting for various people, but so does everyone else.  I’ve also learned that as the day progresses then the slower you move the less hot and tired you get.  Walking slowly one still reaches one’s destination, but later, and not necessarily on time.  That, I am told, is the “African way”. An equivalent 5-minute walk back home in Newfoundland’s present sub-zero temperatures takes me 15 minutes here at a daytime temperature between 30 and 35C.  

So now that I have established my role here and staff on the wards are getting to know who I am, even if not exactly what I do, I am looking forward to the challenges of raising awareness here of the concept of palliative care.  Already nearly half of my time here has passed, and in the remaining four weeks I know I won’t make a huge impact, but I want to do as much as I can.  That’s why I came here.

Mervyn Dean is a palliative care physician recently retired from his post in Corner Brook, NL, Canada.  He has come on a voluntary basis to the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, northeastern Tanzania, to help provide and teach palliative care.