The Front Lines

Biharamulo district is located in the fertile corridor of Tanzania that lies to the west of Lake Victoria and is home to roughly 400,000 people. It is one of the least developed regions in Tanzania. Agriculture (mostly bananas, coffee, cattle, and goats), fishing, and mining are the main industries in the district but a large portion of the population survives by subsistence farming- though some may be able to make a small profit in a local market if the rains make for a good harvest. For many years Biharamulo district hospital was the only hospital for the entire population. There is one medical doctor employed by the hospital, who also serves as the medical director. Due to the overwhelming patient burden, several years ago the responsibility for health care delivery in the district was split between Biharamulo District Hospital and a hospital in a neighboring district so that now the hospital...and the one medical doctor in the district...is responsible for the health of only approximately 200,000 persons. This ratio is, of course, much higher than the average doctor:patient ratio in Tanzania, which is 1 to 25,000. In the United States there is one doctor for every 400 people.

Five assistant medical officers (AMOs) and a handful of medical clerks are responsible for most of the medical diagnoses and treatment plans in the hospital, which has 130 beds though many times more than one patient may be admitted to the same bed. AMOs receive three years of training after secondary school (high school) to become medical clerks. After working for several years in health dispensaries around the country (treating basic medical illnesses like malaria and pneumonia and referring more difficult patients) they can choose to return for two more years of training at one of the teaching hospitals to become an AMO. At Biharamulo and elsewhere they are responsible for just about everything that has to do with patient care. They make diagnoses, decide on treatment plans, perform procedures such as lumbar punctures or pleurocenteses. They run the HIV specialty clinics and do most of the operations in the hospital including cesarean sections, hysterectomies, appendectomies, and even bowel resections. Although he is often pulled in three directions at once due to his administrative duties, the medical doctor makes "major ward rounds" in each of the wards one day a week, during which he sees each of the patients on a given ward, and will help with difficult patients or some major operations whenever the need arises. Medical officers are in short supply, but the nursing shortage is so severe that a ward of almost 70 patients may be staffed for much of the day by only one "assistant nurse" who has had only one or two years of training after secondary school.

Malaria is by far the leading diagnosis in the hospital, followed by severe anemia which is often secondary to malaria. Malaria is so common and complications so severe that it is a national guideline that any child younger than five years old with a fever should be empirically started on antimalarial medication. Because falciparum malaria is the most prevalent species of the parasite in the region "cerebral malaria" is a common complication of malaria in children here and manifests as neurological complications including strokes and swelling of the brain as a result of red blood cells becoming lodged in the small cerebral vessels. Most children who develop this complication do not survive. Pneumonia is another common diagnosis in patients of all age ranges. Diarrhea is a very common complaint and may be simply viral and self-limiting, bacterial and requiring antibiotics, the result of intestinal worms of various sorts that are ubiquitous here, or all-to-commonly the presenting symptom of HIV infection which has a prevalence of about 10% in the region. There are a significant number of patients with TB in the hospital, but surprisingly there were only 98 documented cases of TB in the entire district last year. Meningitis is very common and usually presents very late. In a matter of two weeks I saw three cases of meningococcal meningitis (a very contagious form of the disease) in children, one case of meningitis that presented in such a severe stage that when I did the lumbar puncture to look at the spinal fluid I had to use a syringe to draw the fluid out (usually it flows like water) because it was frank pus, and another child who had presented with such severe meningitis that I had to tell the AMO who was about to do a lumbar puncture that if he did the procedure the child would die right on the table- the child was unconscious and had one blown pupil and one pinpoint pupil which is a sign of severe brain swelling and doing an LP would cause the brain to herniate into the spinal canal due to the pressure gradient. Traffic accidents are extremely common presenting with all types of injuries including complete quadriplegia. Post-partum hemorrhage, hypertensive emergencies, strokes, diabetes were also seen. All too often we had to just give our best guess at a diagnosis because we did not have the lab capabilities to do the tests that would be needed to confirm or deny our hunches.



I was impressed by the scope of the responsibilities held by the medical staff, and I learned much from not only the medical director but many of the AMOs as well, especially about diseases such as malaria and TB and HIV that I have limited exposure to. However it was apparent that the work load was simply overwhelming. In each of the wards (pediatrics, female, male, and surgical) all of the patients are only seen once a week. On other days only the sickest patients are seen. Unfortunately if a nurse is not trained enough to pick out worrying signs or symptoms, or if a parent is unable to differentiate a soundly sleeping child from a child with a decreased level of consciousness, a very ill person may be missed. A number of times when I walked through the wards just to see if there were any sick patients that had been missed I came across florid meningitis or severe malaria that had been missed. At first my frustration was toward the nurses, or the AMOs, or the parents for waiting so long to bring their children to the hospital...but slowly I began to realize that my frustration ought to be directed towards a system as a whole (not just the Tanzanian health system...a system which we are all a part of in some way) that leaves families so poor that even the money it would take to travel to the hospital would mean that they would go without food for a time, a system that only provides one partially trained nurse to care for 70 people, a system that can pay its overworked doctors only $10 dollars a day, a system that provides only one fully trained medical doctor for 200,000 people.

But somehow in all of the overwhelming workload and disease and mournful cries of mothers who just lost yet another child...there were smiles like this one that greeted me every morning when I entered the pediatric ward...and those smiles gave me hope that maybe things will improve for these people who have waited long enough...