Ilula Minnesota Healthcare Conference

Monday and Tuesday were devoted to presenting our seventh annual Ilula Minnesota International HealthCare Conference.  This conference brings us together with our colleagues from across southern Tanzania to learn together, share best practices, make friends, and develop quality improvement plans that teams take back home to implement at their hospital.  From each of 28 hospitals we invite one doctor, one nurse and one pharmacist and one administrator.  They come as a team and together develop quality improvement plans based on what they learned.  This is a great way for us to leave a lasting impact even after we return home.  All our presenters did a great job and all the healthcare professional teams that attended gave positive feedback.

This year we heard a presentation from a hospital team who attended last year and completed their quality improvement project during the year.  By completing their project on improving management of labor they were able to reduce neonatal mortality by 58%, saving over 50 lives. We were all inspired to hear the impact that these quality improvement projects can have.

Our first course was presented in January 2014 with 30 attendees.  Based on extremely positive feedback from the initial conference, our partners in Tanzania encouraged us to significantly expand the conference to offer this educational experience to a much larger audience of caregivers.  As a result, we expanded the 2015 conference to include all 28 Southern Zone Lutheran Hospitals and hosted 100 professionals.  As the conference has grown we have included staff from local nursing schools and local medical authorities.  Again this year we hosted over 130 Tanzanian health care professionals at the conference. 

Our conference is based on 5 principles:

1. Lifelong Learning.  We believe all professionals should contribute to a culture of learning and continuously learn to improve our practice.  We include students and residents in preparation and presentation of the conference. 

 2. Interprofessional teamwork.  We include nursing, pharmacy, administrators, and physicians in both the attendance and presentations.  We emphasize teamwork throughout the conference.  We each bring unique knowledge and skills to share; specifically Tanzanian presenters emphasize tropical medicine and HIV, American presenters emphasize the growing global problem of chronic and non-communicable diseases.

3. Mutual Respect.  We emphasize the ability for all our participants to teach and learn from each other, in spite of our differences in practice setting, culture, and socioeconomic situation.  We include local leaders in planning the conference and select topics based on feedback from participants.  Presentations are delivered by both US and Tanzanian professionals.  We adhere to the highest international standards in the preparation of the educational content and accreditation of the program.  The program is based on a foundation of a longstanding and ongoing relationship.

4. Continuous improvement.  Learning should drive improvement in practice.  We include planning sessions for participants to complete planning documents based on learnings to institute improvement plans upon returning to home hospitals.

5. Sustainable Impact.  We believe that education and improvement are some of the most valuable ways to promote a sustainable positive impact on the health of our partners’ communities.

Our conference is accredited by the Education Department at the M Health Fairview to provide participants with Education credits for participation in this program.

Funding for the course is provided through generous contributions from several foundations and individuals including Global Health Ministries and the Peter King Family Foundation.  All funds raised go entirely to hosting the conference, and support for local Tanzanian staff to attend, including meals, travel and lodging expenses.  We want to sincerely thank all our donors, without their generosity, the course would not be possible.

Overall the conference was a great chance to learn together, build relationships, and plan together to improve healthcare in Tanzania.  I hope we can do it again for many years to come.

An X-Ray for Ilula

7Feb19

An X-Ray for Ilula

Since I arrived, a large portion of my personal time has been devoted to the x-ray need at Ilula Lutheran Hospital (ILH). Read on if you are wondering about why a hospital might need an x-ray machine.

I will start with a bit of history of which I was only vaguely aware. Over the years since I started coming to ILH with learners, I knew there was an old portable machine around. Once I saw it in the hallway of the old general ward, pushed to the side and looking forlorn. But I lost track of it. Until this year when I was in the “new” x-ray area. The room is about 5 years old and has been slowly made acceptable for a new installation. There sat the old machine! Dr. Benjamin Chota told me that it had been used as recently as 2012 when the Tanzania Atomic Energy Commission condemned it or at least shut it down. Dr. Benjamin said that in 2010, 500 x-rays were performed. I hope neither patient nor operator were harmed! He thinks a few more exams were performed in subsequent years. We brought our first students here in January 2011, but I do not recall seeing any x-rays.

An estimate of the number that will be performed in the future is somewhat difficult to forecast. A couple years ago, we tallied the number of patients that were sent to Iringa for x-rays. There were 169. We made some estimates generalized from that. With changes here that, we believe, is a severely understated number. Think traffic. Many more cars, trucks, motorcycles and now bijajis on the road with a concomitant number of increased accidents. This is only part of the issue. Many more medical patients are being seen, including 120-150 outpatients per day. Two years ago there were 7800 admissions and over 15,000 bed-days.

So how does a hospital work without an x-ray? I dunno. Shoulder to Shoulder has been working hard to raise the $100K+ to buy one. We are working with Rotary International and are hoping the Iringa Rotary Club will be the host club as we work with Rotary Clubs at home to raise funds for matching grants.

Leslie Pratt and Steve Moburg accompanied me to the Iringa Rotary two weeks in a row, once for an introduction and a second time to present our case to the club about having Iringa Rotary to be the in-country host for funding through Rotary International. The prospects look good. They graciously listened to my pitch and seem genuinely engaged and are willing to work on the project. The one objection they offered is that the Rotary International process takes a long time.

I am confidant the x-ray will happen, but it has been a long time coming!

CTC (HIV) Mobile Clinic

Thursday, February 7, 2019

Once a month the Ilula Hospital team conducts mobile HIV clinic rounds. The primary purpose is to provide medication for and check the welfare of those HIV positive patients who live too far away to attend the weekly HIV clinic at Ilula. Mostly these are poor people who live more than an hour away from the town and who cannot afford transportation to get to the Ilula HIV clinic. Mobile HIV clinic goes to two sites, each in mountainous villages south of Ilula. The setting is beautiful, with mountains and rolling hills and lush green forests as far as the eye can see.

The team all piled into an Ilula hospital ambulance for the ride to the villages. There were 11 of us in back and 3 in front. The rooftop carrier was piled high with boxes of antiretroviral drugs for distribution. HIV drugs are provided by the Tanzanian government and are free to all who need them. We travelled along dirt roads, bumpy and rutted from rain, up and down steep hills, around sharp turns, across bridges. The ride was something akin to a roller coaster. When we arrived at the first village half of the staff poured out of the ambulance to set up the clinic, while the rest continued on to the second village.

At the first village there were many people already waiting for us. More people were walking to the clinic along the road. There were no vehicles to be seen, everyone arrived on foot. Women were dressed in there most colorful African clothes with babies cleverly tied to their backs with a piece of fabric. Men were there too, but were far outnumbered by the women. The morning began with a speech by the local medical  officer followed by a speech by one of the Ilula nurses. Then we set up a weight station, a prescription station, and a drug distribution station inside the community center building.

There was a long line of people waiting to be helped. The people were serious, there was not a lot of chatter or laughter, quite unlike other gatherings of Tanzanians where people are talking a mile a minute and laughing and joking and enjoying one another’s company. The queue was very orderly except one old man who was protesting loudly and tried to budge. The others just ignored him. There were no angry words or  pushing.  Probably the villagers know this crotchety old man and know just how to deal with him. As each person entered the building, they were weighed at the nursing station and the weight was entered into the paper chart (No electronic medical record here!). Each proceeded to the prescription station where the chart was reviewed for signs of weight loss and a brief series of questions about how they are doing. If there were no new problems or symptoms the patient proceeded to the pharmacy station where they were given a 2 month supply of antiretroviral therapy. Almost everyone takes the same 3 drug regimen combined into one daily pill. Only those who have failed to respond go on to second line therapy. 

We saw 104 patients, 101 of whom were doing well, no weight loss, no symptoms of opportunistic infection, going about there daily business like the rest of the people in their villages. Three people had an acute respiratory illness, one of whom needed further evaluation. There seemed to be so many people with this condition. The line of waiting patients seemed endless. It was hard to remember that although 5% of the people in Tanzania are HIV positive,  the vast majority, 95% , are negative. 

When we finished with the clinic, we all piled back into the ambulance for the ride back to Ilula. On our way we stopped to do home visits for 3 patients who were too ill to attend clinic. These were people, who, for a variety of reasons, were non compliant with taking their antiretroviral drugs. Each of these patients was very ill, lying in a dark mud hut, on a mat on the dirt floor. The suffering of these people was almost palpable.

We new comers came away with some very deep impressions. 1. Medication compliance is absolutely critical. People living with HIV can have long and productive lives if they take their medication. They are much less contagious if compliant, which is so important in reducing the burden of this illness on Tanzanian society. 2. Those people who are non compliant or non responders, endure terrible, really unspeakable, suffering. The mobile HIV team does a great job in ensuring that the most HIV positive  people are taking their meds as prescribed, and are working and productive members of their community. 

Deb Mangham MD

My Role in Ilula

Leslie Pratt writing today. I am a Maternal Fetal Medicine (high risk OB) physician who is now mostly retired. This is my third trip to Ilula. I first came in 2014 at the prodding of my daughter (Laura Hanson) who was a 4th year med student at the time. I was here as clinical faculty and was a bit unsure of my role. I observed rounds, participated in a few Cesarean section deliveries, presented a talk at the 1st annual MN Ilula medical conference and tried to impart a few words of wisdom to our students. And I was overwhelmed by the volume of patients and the lack of resources I saw.

My second trip two years ago was focused on participating in the medical conference which by then was so well attended it was held in a lecture room at the Health Care Institute in Iringa (an hour away). That year I felt I was not only contributing to our students education but importantly to the medical education of our Tanzanian colleagues.

This year the 6th annual Minnesota Ilula International Medical Conference was attended by 130 participants, the largest audience yet. It was held in a new and even larger conference hall. Over the two days of this year's conference we heard presentations not only by members of our group, but importantly by several of our Tanzanian colleagues.  

I have spent most of my time at Ilula hospital doing ultrasound this trip. Perhaps the most meaningful part of this year's trip has been spending several days introducing two of the new Ilula physicians to ultrasound. I have now discovered what my role is here. And why it is worth 26 hours of air travel, 12 hours of bus travel, countless meals of beans and rice, and having to always sleep under mosquito netting. My role is to help these very dedicated men and women take care of their pregnant patients with the most knowledge and best resources we can give them in a part of the world where a woman’s risk of of dying in childbirth remains unacceptably high.

Today is the last day of the Ilula-Minnesota International Health Care Conference, and I present today. I have never spoken in front of more than twelve people and I heard the conference hall echoes, so it has to be a large space. Walking up to the building I see a journalist snapping candid photos, a registration table with colorfully dressed participants huddled around it and as I walk inside the building I feel a sense of disguised anxiety or excitement bubble inside me. The conference hall has rows of tables covered in brightly patterned fabric with Tanzanian nurses, accountants, laboratory technicians, doctors, nuns, pharmacists and hospital administrators sitting attentively waiting for the the conference to begin. As Dr. John introduces the day’s schedule, my mind wanders out the big bay windows and I forget about my talking points and feel immensely present under the tin roof and hum of shuffling chairs.

My conference “job” for the day is to be the photographer. So, I tried my best to be a chameleon in each room I pop into. I sat in on everyone’s talk for at least 5 minutes, trying not miss any memorable moments such as Sarah’s debut as a pregnant pre-eclampsia patient.  For the most part it was our Minnesota group that was presenting on topics.  While I learned about chronic kidney disease and intimate partner violence I wanted to hear more from our Tanzanian colleagues. Three talks were happening at the same time. I shuffled between buildings, scurrying away from the beating sun and by the time I knew it, it was my turn to present. I was nervous.

I wondered how relevant me harping about the devastating consequences hypertension will be.  Will I convince anyone that blood pressure control is important? I worried that my minimal clinical experience will disengage people before I reach my second slide. I felt unprepared to answer questions about medical management of strokes in Tanzania. While, two weeks in Ilula Hospital provided context to the health care infrastructure, I didn’t know what resources and training the participants had in order to be “helpful”. Nothing is worse than wanting to know the answer and hearing “I don’t know”. I, myself am still trying to get comfortable with the idea that we actually don’t know a lot about how our bodies work. 

I stand up tall, trying to not think too much, and begin my “schpile”. Before I know it, I was done talking and was relieved to hear another voice fill the room. A doctor in the front row asked a very relevant question about whether anti-retro viral therapy increases the occurrence of strokes. This shocked me since this question did not remotely cross my mind, albeit incredibly relevant. Another doctor asked how to tell the difference between ischemic and hemorrhagic strokes. I prepared a slide about relevant symptoms to each, but blanked when he asked me. I knew he was making me aware of the fact that CTs and MRIs are not a common tool here. I felt a little ashamed that I did not prepare my talk for my audience well enough. It was clear that Tanzanian health care workers had challenges with available resources. 

As the conference was coming to an end, birds began scratching at the tin roof and Randy motioned at Sarah flapping his arms and pointing at the barn doors. I chuckled, as Sarah without protest and a gentle smile walked outside to clear the commotion. We wear many hats here in Ilula! The conference finally finished on a very high note with a “special” song, that I doubt anyone on this trip will forget.

After the conference, Minnesotans and Tanzanians from Ilula Hospital boarded the bus, and we drove to Mama Iringa’s for dinner. The Italian eatery was a welcome change from our fried food diet.  Don’t get me wrong, I love all the food Anna cooks for us, but who doesn’t miss a Neapolitan pizza.  I was sitting between Dr. Malala and Dr. Benjamin, shoulder to shoulder. Of course, Dr. Malala ate some pizza but it was clear that pizza was not as appetizing as umgali with a tomato sauce. Dr. Benjamin, commented that in medical school after long days of studying he would order a pizza. At that moment, I felt very connected, either by experience or by eating together. To end an already great dinner, Dr. Saga brought himself and the whole table to tears with a rendition of our “special” conference song. We laughed, squealed and cried to the point of silence. I couldn’t be happier that night.

Day 15 Ilula Blog/Monday/28Jan19/

The Ilula Hospital area bells rang as usual at 0500, 0545, and 0600. That sound usually signals the sleeping runner/walker members of our group to take a jaunt before the sun is up, but not today. After tea/coffee and one of Anna's fritter balls, the packed coaster bus of 30 (some hospital staff and those staying with Dr. Saga included) left the compound at 0636 for the ride to day 1 of the Sixth Annual Ilula-Minnesota International Healthcare Conference in Iringa (at the Primary Health Care Institute).  Edyta, Kat, Kari, and Michaela however, separately taxied from the compound to an all-girl Maasai school and the Ilula Orphanage Program for I.T./electric circuitry initiatives. Alas for today, we had no church service and morning report.

The conference bus arrived at about 0750 and the group quickly set up the registration table, audio-video equipment, and computer connections for the 0800 start. The King family group, a major meeting sponsor, welcomed us and attended part of the meeting. 

The 2-day meeting agenda may be available on another document for those interested. The conference seating was full with over 120 attendees including presenters. Overall today’s meeting was well received and participants averaged about 3 questions (asked in the usual African respectful and quiet way) in the limited time after each of 12 presentations. There was also a separate afternoon breakout session on preeclampsia/eclampsia for those interested.

The return bus left Iringa at 1745 and arrived in Ilula at 1850. Anna and her kitchen assistants provided our evening meal which included the usual yellow rice, spaghetti, a meaty red sauce, a mushroom sauce dish, pineapple and mango pieces, and a spinach dish. And we were very hungry after a long day….

The fields and hills around Ilula appear bountiful and verdant (the rainy season has started) and common crops seen are corn, beans, and tomatoes. 

Some trivia:

Price of gasoline: 2359 Tz shillings/L

Exchange rate: (100 USD bill): 2300 Tz shillings /1 USD

Common bottled water brands: Kilimanjaro, Udzungwa

Common beer brands: Kilimanjaro, Serengeti, Safari, Tusker

The Ilula hospital has not been able to do x-rays, ecg, and serums for creatinine, albumin, sickle cell testing, iron, or liver function….HIV-RNA now is being processed regularly (sent to Iringa), but cd4 not so much

Michael Madalon

Monday and Tuesday were devoted to presenting our sixth annual Ilula Minnesota International HealthCare Conference.  This conference brings us together with our colleagues from across southern Tanzania to learn together, share best practices, make friends, and develop quality improvement plans that teams take back home to implement at their hospital.  From each of 28 hospitals we invite one doctor, one nurse and one pharmacist and one administrator.  They come as a team and together develop quality improvement plans based on what they learned.  This is a great way for us to leave a lasting impact even after we return home.  All our presenters did a great job and all the healthcare professional teams that attended gave positive feedback.

Our first course was presented in January 2014 with 30 attendees.  Based on extremely positive feedback from the initial conference, our partners in Tanzania encouraged us to significantly expand the conference to offer this educational experience to a much larger audience of caregivers.  As a result, we expanded the 2015 conference to include all 28 Southern Zone Lutheran Hospitals and hosted 100 professionals.  As the conference has grown we have included staff from local nursing schools and local medical authorities.  Again this year we hosted over 100 Tanzanian health care professionals at the conference. 

Our conference is based on 5 principles:

1. Lifelong Learning.  We believe all professionals should contribute to a culture of learning and continuously learn to improve our practice.  We include students and residents in preparation and presentation of the conference. 

 2. Interprofessional teamwork.  We include nursing, pharmacy, administrators, and physicians in both the attendance and presentations.  We emphasize teamwork throughout the conference.  We each bring unique knowledge and skills to share; specifically Tanzanian presenters emphasize tropical medicine and HIV, American presenters emphasize the growing global problem of chronic and non-communicable diseases.

3. Mutual Respect.  We emphasize the ability for all our participants to teach and learn from each other, in spite of our differences in practice setting, culture, and socioeconomic situation.  We include local leaders in planning the conference and select topics based on feedback from participants.  Presentations are delivered by both US and Tanzanian professionals.  We adhere to the highest international standards in the preparation of the educational content and accreditation of the program.  The program is based on a foundation of a longstanding and ongoing relationship.

4. Continuous improvement.  Learning should drive improvement in practice.  We include planning sessions for participants to complete planning documents based on learnings to institute improvement plans upon returning to home hospitals.

5. Sustainable Impact.  We believe that education and improvement are some of the most valuable ways to promote a sustainable positive impact on the health of our partners’ communities.

Our conference is accredited by the Education Department at the HealthEast Care System to provide participants with CME credits for participation in this program.

Funding for the course is provided through generous contributions from several foundations and individuals including Global Health Ministries and the Peter King Family Foundation.  All funds raised go entirely to hosting the conference, and support for local Tanzanian staff to attend, including meals, travel and lodging expenses.  We want to sincerely thank all our donors, without their generosity, the course would not be possible.

Overall the conference was a great chance to learn together, build relationships, and plan together to improve healthcare in Tanzania.  I hope we can do it again for many years to come.