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.