My trip to Arusha_Tanzania
Ben Casey (Medicine)

Walking in to the hospital on my first day I was filled with anticipation. I really didn't know what to expect. Horror stories abound and on your way in, do make you think, "What the hell am I doing here?" So, as I stepped onto the general medical ward to meet the local intern that I would be shadowing, I have to confess, I was a bit nervous. However, the smiling face of Dr D. soon put me at ease. He was really welcoming and willing to show me the ropes. However, it was still set to be a bit of a shock.

So having been shown the wards we started a ward round. It did not take long for the challenges facing these doctors and nurses to become apparent. Many of the patients had malaria and one was suffering a case of cerebral malaria which made him quite aggressive and difficult to control (this duty left to other patients rather than medical staff). Two other patients had tetanus, a condition I had never seen before, probably reflecting the success of the UK's vaccination program started in the 1960's. Other patients on the ward had TB or HIV/AIDS but a significant number remained undiagnosed due to a lack of diagnostic testing facilities and equipment.

Nearly all medical treatment is paid for by the patient or the patient's family. The hospital does receive some government funding but it is incredibly limited. If we think we have problems in the NHS in the UK, they pale in comparison.

On one occasion in my second week, when I was on the female ward, the hospital received two lumbar puncture kits. There were five patients on the ward that were either showing signs of encephalitis or meningitis who had been waiting some time (over a week in one case) for the appropriate investigations to be done. I watched as the two kits were used to obtain samples from all five of the patients. Not ideal but it was the only way these women were going to get the investigations they required. This was just one of the occasions when it became abundantly clear to me how lucky we are in the UK, where we have cupboards full of this sort of equipment. It could have been very easy for me to be shocked or horrified at what I was seeing and hearing but on the contrary I was very impressed by the way the doctors kept their heads when faced with these very difficult circumstances.

One department that did seem to work well was radiology. Requests for x-rays were promptly acted upon and reports, although brief, were nearly always available as quickly. Unlike in the UK where we have become accustom to the idea of viewing x-rays on the computer the x-rays in this hospital were still provided on film. There were no light-boxes to view them on, but luckily Tanzania is not short of bright sunlight.

Despite my grim observations, the four weeks I spent on the general medical wards were great. I felt like part of the team very quickly and was always greeted with a warm smile and a "habari za asabuhi" (good morning in Kiswahili) or "karibu sana" (you are very welcome). I was encouraged to examine patients and was able to gain significant experience with conditions that are not as frequently seen in the UK, particularly malaria and TB.

In the remaining two weeks of my placement I spent time in the psychiatric department. This was set to be another massive eye-opener. The department is entirely nurse-led and is run as an out-patient clinic. There are no psychiatrists in the entire hospital and apparently, there are only 12 psychiatrists in the whole country.

My supervisor in the department was Sister G. She had over 20 years experience in the provision of psychiatric care but her formal training in the field was very limited. She still had a wealth of knowledge and experience that she was willing to share and that started straight away. She would essentially let me run the clinics as if they were my own. I got to interview all of the patients, suggest diagnoses and treatment plans.

On my first day I was immediately confronted with a very psychotic patient. He had been diagnosed with schizophrenia many years before and was being treated via monthly visits to this clinic. He sat down opposite me and said "shikamoo baba" (a formal greeting in Kiswahili) but that was to be the only straight forward moment within the whole consultation. We asked him how he was coping and he proceeded to tell us about the terrifying hallucinations that he had been experiencing. A hallucination he was actually experiencing as we were talking. It involved hands bursting out of his spine and trying to grab his face. He was often obviously distracted by them as he would often recoil from 'the hands'.

This was already unlike anything I had experienced in England, where patients have their symptoms more adequately controlled. In this department floridly psychotic patients were the norm and every day brought with it new surprises.

The department also treated patients with epilepsy, seen as a psychiatric problem rather than a neurological problem within the community in Tanzania. There is still some belief that the seizures are due to some sort of possession of the mind perhaps by spirits or magic. Indeed psychiatric help is often only sought after a traditional healer has been consulted. This is still an important part of the culture and can actually postpone adequate treatment. The fact that epilepsy falls under the remit of psychiatry does have one benefit and that is that the medication is free of charge. Unlike all other departments psychiatric patients receive free medical care. This did make prescribing very easy but the arsenal of medications that is available in England is no way matched by that in Tanzania. In England when one medication doesn't quite work or the side effects are too much to cope with then there is often another medication in the same class that can be trialled. In Tanzania however, it is a one size fits all approach to treatment.

The time I spent in the mental health department was probably the highlight of my elective. It was really hard and challenging work at times but it was an area where I felt I had made a big impact and I felt particularly useful (if only for my BNF). It was a real shame when my time came to an end.

My entire placement in the hospital was brilliant. Although there were some obvious challenges I found everyone, patients, doctors and nurses alike, to be very warm and welcoming. I was encouraged to learn and to help where possible and in many ways it has helped give me some confidence in myself which will stay with me as I embark on my career in England. I hope to get back to Tanzania again later in my career and maybe be a bit more useful. It is a country that will always have a place in my memory and my heart.

And don't forget that the Programme Manager, Freddy is a BIG Chelsea fan!

There is an extended version of this report here.