Wednesday, March 12, 2008

same same

above: Guy, Bonifas, the ART nurse and peer advocate at Keni Health Centre, Rombo district

Sara, a nurse, Steve and Keni Health Centre patients

above: the Matron of Keni Health Centre with Bonifas, the HIV clinician, in the clinical room

Same: everyone pronounces the district and town name as “Sah-may.” But there are some Tanzanians who half-jokingly tell the story of the British colonialist who drove through the Same region in his jeep, watching the rolling hills behind the expansive valley floor and announced that everything looked the “same.” And as another unfortunate vestige of colonial power, the name stuck. But it sounds better pronounced “Sah-may.”

Sadly, by the fourth week of my mentoring-of-mentors work at the HIV clinics, things were really starting to feel same same. Same was this way. Huruma was this way with the roll-out due to poor district leadership.

Clinics had run out of basic HIV drugs, such as efavirenz. Most clinics we visited had broken CD4 machines, which (when working) provided one of the few critical lab tests that we needed to manage patients with HIV. They have the machines but no one had been trained on how to maintain or fix them.

During a majority of the clinics, I was the only clinician there in the mornings. The patients very patiently waited from 7 am to see them. But I had to run around and look for the Tanzanian clinicians so that they could see the patients queued up to see them. It made me wonder what happens when there are no visitors like me to pull them from their meetings and such to go see patients. And then I realized from the patients what had been happening. Apparently sometimes only the nurses saw them, and even though they were untrained to give HIV medications, they gave them medication refills without doing a clinical assessment. Sometimes the hurried clinician came at 1-2 in the afternoon and just whipped through the long line of patients, nodding at their complaints but not doing a damn thing about them. Just refill, refill, refill, follow-up next month.

The reason I found this out was because when I saw the patients with the Tanzanian clinicians, they would tell us about some problem they’ve had for the last six months. Or over the last three years. These were big things, like “their legs have been on fire all night.” (A way that patients describe their peripheral neuropathy.) Or “I have been coughing and losing weight for the last three months but they keep on giving me amoxicillin and it doesn’t get better.” Or “last month they did not give me the yellow pill I usually take.” (This is how I found out that some of the sites had had be out of efavirenz, a vital HIV drug, for one or two months.) Yet there was no note of anywhere in the chart. The patients were probably just hurried through a long line, and the clinician just nodded to their complaints and gave them refills.

The patients put up with terrible service and even worse clinical management. Yet many of them remain grateful that they are receiving medications at all. The culture of acceptance is deeply ingrained. There is no ACT UP Tanzania.

There are, of course, a few nurses, clinical officers and medical officers who possess decent medical acumen, but sadly I found a vast majority of the clinicians to be very poorly trained. It’s the fault of the system and its complicit corrupt leadership. It’s hard to become a good clinician (or anything, for that matter) if your schools don’t teach you the skills you need to use – or if your leadership doesn’t allow you to do the duties you need to do, or skims off resources (such as using the HIV clinic’s land cruiser as his own personal vehicle). Tanzanian training lags behind that of the Kenyans’ I have worked with in the past. This was an unfortunate realization, as I had high hopes that the people led by the Mwalimu (Teacher) Nyerere would have a solid education. Not so.

Most people I worked with lacked critical thinking skills in their evaluation of patients. They stared at me blankly when I would say, “Do you think that the cough can be due to something other than bacterial pneumonia? What are other possibilities?” They stared at me again when I would suggest that they write down a differential diagnosis and follow-up closely if a patient did not get better with amoxicillin. There is very little concept of the provision of quality care. Most people just wanted to get through their day and probably be left alone by someone like me.

It is these clinicians, the ones who are entrenched in the bad habits established at their district HIV clinic sites, who we are trying to train to be mentors of the roll-out clinics in the more rural, remote sites. This is a frightening proposition: the blind leading the blind in HIV care. The patients suffer the most. In the end, the entire community suffers – everyone suffers.

I am not surprised that in a recent study from an HIV clinic in Moshi, Tanzania, 30% of the patients surveyed had treatment failure. With the system as fragile and poorly organized as it is, we will be seeing more and more treatment failure as time goes on.

Guy and I wrote several frank and thorough reports to discuss directly with the clinic staff and the EGPAF officers. I was told in a roundabout way that my writing might be too bold and brazen and that I would get resistance. That my writing was not culturally sensitive – because Tanzanians are never this direct. But I am not Tanzanian and can’t pretend to be. And the lack of direct feedback is partially why Tanzanian medical care is so impoverished. No one pushes them to do better. I don’t think that providing dangerously poor medical care is a “cultural thing.” I can’t imagine a culture that is happy to do such a thing on purpose.

Still, there is hope. There is no where to go but up. There are a few good leaders out there in the clinics, scattered but not yet swept up by NGOs and foreign countries. The clinicians at the rural and remote health facilities are happy and grateful to get any training or mentoring, since they’ve been neglected for so long. Since they are completely new to HIV care, there is the possibility of teaching them the smart, higher quality way to care for patients with HIV. Even if they don’t have the fancy equipment or facilities of the district clinics, they have time. They have time to start clinic in the morning and to listen to patients when they have problems. They have time to do a decent physical examination. They have time to think through a good management plan. But they need to be taught how to do these things. We just have to hope that they are moving in this direction after we leave and must rely on the in-country mentors to lead them.

No comments: