Monday, September 1, 2008

Shimbwe Village: where there is no doctor

[above: Fides, Regina, Luciana and their families in Tesheni sub-village]

[above: a short video of Joelle and Beatus describing their work]

Last Saturday Joelle brought me along her round of home visits in the Tesheni sub-village of Shimbwe. She is coordinating the health program of the Minjeni Women’s Project, a small and very grass-roots organization started by a Tanzanian woman from Shimbwe who became a nurse. Joelle makes her rounds with the sub-village leader – in Tesheni, Beatus came with us and helped to identify where the sick people were.

We weren’t just seeing patients in the rural village – we are seeing patients in the rural sub-village. We hiked on the slopes of Mount Kilimanjaro on narrow, steep, packed-dirt pathways to get to the mud-brick homes. It is absolutely, incredibly beautiful. We are surrounded by lush mountain flora, waterfalls, and small family shambas (farms) with mixed crops of coffee, corn, and greens. If it was rainy season, I would have fallen multiple times and been covered completely with mud while evaluating people. Mud-covered, huffing and puffing Sophy, seeing patients where there is no doctor. And no electricity. And no running water. Thank goodness for Purell hand-sanitizer.

Yee-haw! It sounds super-cowgirl-medicine till I tell you that we traveled there by a beat-up mini-van from the bustling international town of Moshi.

Contrast this with the patients that we met at Ushetu lower-level health centre in Kahama District. People still walk 50 km on foot in the hot, dusty Shingyanga region to get to Ushetu. It takes them three days to get to their nearest clinic. This is an improvement; they used to have to walk 80 km to get to Kahama District Hospital before the HIV antiretroviral roll-out, just two months ago. I would be almost afraid to go there and uncover all the untreated illnesses there – it seems overwhelming.

Shimbwe village, on the other hand, is in the rural Moshi district. It’s a 30-45 minute, 800 shillingi daladala ride away from Moshi town and the regional referral hospital of Mawenzi and national referral (and private religious) hospital of KCMC. Yet it’s clear that the people who live in Shimbwe don’t have access to adequate health care.

I can identify three main reasons:
1) Health care is costly: 800 shillingi for each way of travel is still prohibitively expensive for people, particularly single or widowed mothers who also have to care for numerous children and barely make 2,000 shillings a day to support their entire families. At KCMC, people have to pay expensive registration fees. At many health facilities, they are also asked to pay bribes to be seen the same day. Unless they are HIV-infected, they have to pay out-of-pocket for their medications.

2) Getting to the facilities is arduous for those who are ill: People are simply too sick to make the journey down to Moshi town. They are also often turned away due to long queues. People often wait from the break of dawn only to be told at closing time that the clinician doesn’t have time to see them.

3) Even if people are seen by a clinician, the quality of care is often deplorable: Negligence, missed diagnoses, and mis-management abound. It’s sad but true, and individual clinical officers and medical officers are not entirely at blame for this phenomenon. It’s probably due to a mix of crappy clinical training (i.e. A physical exam? Differential diagnosis? What’s that?), poor pay (i.e. good people leave $200-300/month clinical jobs to take cushy office jobs with NGOs that pay at least 3 times as much), and poor conditions (i.e. who wants to be a doctor when you can’t even get a basic lab such as a gram stain or creatinine level?).

Back to Tesheni. We saw five patients that day. Home visits take a long time but are great because you can see the context in which a person lives. It’s a distinct privilege to get such a snap-shot into a person’s life. One woman had been subsisting on only ugali na ndizi (corn mush and banana) for the last few years had developed leg pain and weakness to the point of not being able to walk during her pregnancy. Her baby has significantly deformed legs. I think they have malnutrition, manifesting as B12-deficiency peripheral neuropathy for the mom and Vitamin D/calcium deficiency rickets for the baby (by way of Mom’s vitamin deficiency and breast feeding). If I’m right, we can treat this – and cure them of their symptoms. The sad thing is that this woman had spent a small fortune going to KCMC to be evaluated over the last year– only to be diagnosed with “hysterical ataxia” (a disrespectful way to say that a woman can’t walk because she’s nuts) and “weakness of unknown cause.” You would think that a national referral hospital of Tanzania would be able to diagnose a nutritional deficiency.

Another woman complained of coughing since 1995 and a constellation of vague symptoms, including abdominal and back pain. I think she has peptic ulcer disease, and we will give her triple therapy for helicobacter pylori.

It’s truly rewarding to do home visits in a place like Shimbwe, where there is no doctor. And where there is very little access to good doctors. Hopefully in this very short visit we have helped a few people with curable diseases.

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