Usangi and the Pare Mountains

above: Mama, Juma, and me at the Usangi clinic

above: Ally and his flapping origami crane; he wants to be a doctor! We'll work to make that happen.

Interesting things happen when the power goes out:

The world gets quiet.

You start to hear each other and the animals and the water and the wind.

You take your time.

Your laptop works.

So here I am, sitting in the dark on a lousy foam mattress with unwashed sheets in my Mhako Hostel room, my spine sinking into the bed, listening to the insects and birds outside, the flying insects inside, the chatter from the bar downstairs of men talking over cigarettes and beer and the noise from battery-powered radios… and typing this on my laptop.

I guess I could have sat in the dark with Guy and Steve downstairs, but being the only female guest in a room full of smoking, drinking, belching men is not very fun – with power or without.

Despite my downgrade in standard of living here, I have been enjoying my stay in Usangi. Usangi is a remote town in the Pare Mountains of northern Tanzania. There is a district hospital up here for no other real reason besides that an influential politician is from Usangi and buttered the ministry up to build a district hospital here. People from the district have to travel up several gnarly mountainous dirt roads in order to get to the hospital. In fact, we visited a lakeside village called Kagongo today, in the valley between several of the mountains. The patients in the HIV clinic have to be ready at 4 am to catch the fish truck up to Mwanga, then two separate dala dalas (minivans) up the mountain to get to the clinic by 10 am. And it costs 10,000 shillings, the equivalent to a fourth of a month’s salary for the average Tanzanian.

We are here to start rolling out HIV care to the rural health centres, so that people with HIV from Kagongo can get their care in Kagongo rather than spending 12 hours a day in rough transport and paying half their month’s earnings to get to the Usangi clinic. Right now, there are about 30 patients coming up from Kagongo to Usangi for their care. But the ministry of health suspects that there are at least a hundred more people who need to be in care and treatment in Kagongo. The fishing village is full of young men making lots of cash money from selling fish… and young women trading sex for food. It’s like Lake Victoria in that way. If that’s not a breeding ground for HIV, I don’t know what is.

Kagongo needs our help to become an HIV clinical site. It only has one clinician and two nurses. The clinician is straight out of school and internship. And one of the nurses is planning to transfer to Moshi as soon as she can. That leaves us with a limited staff with limited experience who need a lot of support to become competent in caring for HIV-positive patients. And HIV is one of the most complicated chronic diseases to manage.

We’re making it happen. Here’s how: the health centre staff gets a week-long HIV/AIDS training session. A few weeks later, we bring them up to the district HIV clinic in Usangi to see first-hand how the clinic works and to work with an experienced staff member from the Usangi clinic. We (the UCSF TZ crew) train the Usangi staff to mentor the Kagongo (and Kifula) health centre staff for at least two clinic days in Usangi. We also do a bit of teaching for all staff and some direct mentoring when we see mistakes in clinical practice. After we ensure that the health centres have infrastructure (rooms, furniture, medications, forms), we start transferring some of the patients seen at Usangi to their local health centres. The Usangi site sends a clinician and a nurse down to the health centre during their clinic days to mentor them twice a month. Once the health centre staff feels ready to take off their training wheels, they start having clinics on their own, and the Usangi staff comes to mentor and monitor quality once a month. The Moshi EGPAF Tanzanian staff also visit periodically for quality control. We do a follow-up visit in about half a year.

This model of intensive mentoring is new in Tanzania. Most practitioners are simply thrown into clinical situations and are expected to figure things out. This results in very mixed safety and quality of care. We’re hoping to prevent this from happening to HIV care.

We have a good team now at the Usangi district hospital; they are key in making this plan work. Previously the Usangi site was one of the least organized, but now with Makapa Fellows (Tanzanian superstars picked and hired by the Global Fund given higher salaries to work in remote and rural areas), the site has improved tremendously. It makes an enormous difference for my quality of work to be able to mentor and teach a staff that is interested in learning and developing their skills. It is also a treat to be able to work with smart, savvy Tanzanian women like Tersesia Kasunga – the Makapa clinician that spends most of her time working in the HIV clinic in Usangi. She’s a quick learner and very good with patients – traits that I wish I could find more often in other clinicians.

It was quite gratifying after last week’s fiasco in Karatu to show up on the first day in Usangi and see 15 eager health centre and Usangi staff wanting to learn more about HIV care and treatment. Then the health centre staff stayed to get mentorship from Usangi staff on their two clinic days. We visited the Kifula and Kagongo health centres today to ensure that they have what they need to start seeing patients. And on Friday we will put together a roll-out strategy and work plan for the district. This is exactly what we came to do. Imagine being able to do it! So nice.