This will be my last blog from Tanzania. I’m going to spend a couple of days visiting the island of Zanzibar – pure vacation, nothing to do with work – and then begin the trek home. My time here has not been as fulfilling as I had hoped, which naturally has been disappointing. Nonetheless there have been positive aspects, and now I know how things are here I hope I can use that knowledge to ensure a more productive future visit. I have no doubt of the great need here for palliative care, although awareness of that need by many healthcare staff, and even by some deserving patients, is somewhat lacking.
The biggest disappointment has been the lack of opportunity to teach the medical students and junior doctors. Earlier discussions going back a year had led me to believe that such teaching was to be one of the main reasons for my visit, but somewhere along the way the lines of communication broke down. The medical school is administered somewhat separately from the hospital, but all negotiations regarding my visit were between the hospital administration and me. My assumption that information was being passed to the college proved incorrect, but knowing this I am prepared for next time. My positive teaching experience occurred when I eventually made contact with the nursing school, where the senior staff were not only keen to have me help out with their current programs but also to discuss my future involvement.
Many people who have worked here for a long time, or have previously worked here for brief periods, have tried to tell me that what I have experienced is the “african way,” although exactly what that way is varies according to whom you speak. As I’ve previously mentioned in these blogs, everything does happen at a slower pace here. There no doubt is an African way but I don’t agree with blaming it for everything that doesn’t work out. In my case misunderstanding and miscommunication seem more likely. I also recognise now that part of the problem here was that there is not and never has been a palliative care service, so that I couldn’t “slot in” to an existing service, as visiting colleagues in gynaecology and pediatrics were able to do with comparative ease.
Nonetheless, I certainly value the experience I have had here, both of working in a different medical environment and of experiencing a different social environment and culture. There have been a few times when a patient’s comment has taken me aback. For example, in this part of Tanzania there is no shortage of food – roadside stalls are frequent and loaded with fresh produce – so when, wanting to know if a patient still had any appetite, I asked her if she was eating normally I was not expecting her reply, “Oh yes, when I can afford food I eat.” There is a lot of poverty here, and that influences the need for palliative care.
For example I saw one man in his 40’s who had a total esophageal obstruction due to a tumour. This could not be adequately managed at KCMC, so he needed to go to the Ocean Road Cancer Institute in Dar es Salaam for radiation treatment and/or stent insertion, but he couldn’t afford to go, leaving him but with one option – to go home and starve to death. A gastrostomy tube could have been an option if there was someone to look after it in his home village, but there was not, and the risk of infection or tube displacement is one that from experience the surgeons don’t wish to take. What really registered with me was that the patient was quite philosophical about this, and the attending physician did not see the situation as anything out of the ordinary. As time went on I realised that sadly it isn’t.
Based on my experience I would not discourage anyone wishing to come to work in the developing world. Indeed I would encourage them to go ahead. However, be prepared for disappointments and unexpected challenges. Challenges were partly what I came for, and although the challenges were not the ones I expected, I am hoping that with the experience gained I can plan to return and make a more useful contribution.
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.